Medicare Secondary Payer

M 

MAC Medicare Administrative Contractor 

Medical Necessity A medical procedure or service must be performed only for the treatment of an accident, injury or illness and is not considered experimental, investigational or cosmetic. 

Medi-Cal Medi-Cal is California’s Medicaid program. Provides health services for categorically eligible and low-income persons. www.medi-cal.ca.gov. 

Medicare A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). www.medicare.gov Medigap Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. 

Medigap is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference. 

Modifier In CPT coding, a two-digit add-on or five-digit number, representing the modifier, placed after the usual procedure code number. The two-digit modifier may be separated by a hyphen. 

MSP Medicare Secondary Payer

N

 N/C Non-Covered Charge -- Procedure is not covered by health plan.

 NPI National Identification Number – Standard unique 10-digit identifier assigned to health care providers by CMS. It replaces all previous identifiers. 

P 

Palmetto GBA Effective September 2, 2008 Palmetto is the Medicare contractor for Jurisdiction 1 Part A/B. www.palmettogba.com/J1B 

Participating Provider A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan.

 PCP Primary Care Physician -- The doctor you see first for most health problems and may talk with other doctors and health care providers about your care and refer you to them. 

POS Point of Service -- An insurance plan that allows a patient to choose doctors and hospitals without having to first get a referral from his/her primary care doctor. 

PPO Preferred Provider Organization -- A plan that contracts with independent providers at a discount for services. The physicians in a PPO are paid on a fee-for-service schedule that is discounted, usually about 10% to 20% below normal fees. A patient can use a physician outside of the PPO providers, but he or she will have to bear a bigger portion of the fee. 

Procedure Code CPT or HCPC code used to describe the service rendered. 

PTAN Provider Transaction Access Number -- Also known as your legacy Medicare number. 

R 

RA Remittance Advice -- Supplied by the payer to outline payment for submitted claims. Also contains explanations for claim denials. Also referred to as EOB. 

Referral Permission from your primary care doctor for you to see a specialist or get certain services. Responsible Party The person(s) responsible for paying a patient’s office or hospital bill, usually referred to as the guarantor 

S 

Secondary Insurance Extra insurance that may pay some charges not paid by the primary insurance company. 

Skilled Nursing Facility Typically an institution for convalescence or a nursing home. The skilled nursing facility provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care. 

SOF Signature on File Supplemental Insurance An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell 

Supplemental Insurance for Medicare. 

Subscriber For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder. 

T

 TAR Treatment Authorization Request -- An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 

Tele Comm Support Internet software or hardware support with the staff of Tele Comm Computer Systems, Inc. 

Term Date The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage. 

TIN Tax Identification Number -- Also known as Employer Identification Number (EIN) 

TOS Type of Service -- A description of the category of the service preformed. 

TTY Teletypewriter for the hearing impaired 

U 

UPIN Provider Unique Personal Identification Number -- No longer utilized as of May 23, 2008 

Untimely Submission A medical claim must be submitted within the time frame given by the insurance company or the claim will be denied. 

X 

XPrint Terminal Emulator that enables printing from the Legacy Medical Billing system 

XTerm Terminal Emulator to connect the Legacy Medical Billing system