Medicare Part B 101 Manual

Appendix 2: Glossary of Terms

The Glossary of Terms listed below are in alphabetical order.

Term	Definition
ABN	Advance Beneficiary Notice: A formal notice of noncoverage that a provider gives a fee-for-service Medicare beneficiary if the provider believes the service will be denied because it’s not considered medically reasonable and necessary for that patient, in that particular instance.
ADR	Additional Development Request: A letter that is sent to the provider to request additional information with regard to a claim.
ASCA	Administrative Simplification Compliance Act
Assigned claim	A claim that directs payment to the provider or group.
Beneficiary	An individual who is entitled to Medicare Part A and/or Part B.
CCN	Claim control number
CMS	Centers for Medicare & Medicaid Services
CMS-1500 claim form	The only claim form approved by CMS for providers to submit Medicare Part B claims.
COB	Coordination of benefits
Coinsurance	A cost-sharing requirement that provides that a beneficiary will have responsibility for a portion or percentage of the costs of covered services.
CPT	Current Procedural Terminology. A five-digit numeric code that indicates the exact service rendered. This procedure code system was developed and is published by the AMA. It is the procedure code system recognized by the Medicare Program.
Customary charge	The charge the provider customarily bills his/her patients for a specific service. Nonparticipating physicians may not bill their customary charge unless it is equal to or lower than the limiting charge. Nonparticipating physicians may increase their customary charge at any time as long as it does not exceed the limiting charge.
CWF	Common Working File. Beneficiary data and claim history clearinghouse which is used by fiscal intermediaries and carriers and is controlled by the CMS.
Deductible	The amount of expense a beneficiary must first incur before Medicare begins payment for covered services. The deductible amount is announced by the Medicare program every year.
Descriptor	The word(s) or phrase(s) used to identify the procedure that was performed. May also be referred to as nomenclature. This text defines the code in a code set.
DME MAC	Durable Medical Equipment Medicare Administrative Contractor
DMEPOS	Durable medical equipment, prosthetics, orthotics and supplies
EDI	Electronic data interchange
EFI	Electronic file interchange. The electronic process for NPI bulk enumeration.
EFT	Electronic funds transfer. Direct bank deposit of Medicare payments.
EMC	Electronic media claims. The term used to denote claims submitted electronically rather than by paper.
Enrollment Date	The date on which the beneficiary became eligible for Medicare benefits (Part A) or the date on which the beneficiary enrolls in Medicare Part B.
ERA	Electronic remittance advice
FA	Fraud and abuse
FCN	Financial control number. This number appears on the provider remittance when a payment offset has occurred.
HCPCS	Health Care Common Procedure Coding System. A standardized procedure coding system to identify provider services and supplies. HCPCS codes are divided into three levels. Level I codes are CPT codes provided by the American Medical Association. Level II codes are temporary nationally assigned CMS codes for services/procedures not identified in the CPT coding system. Level III codes are local carrier assigned codes approved by CMS.
HIPAA	Health Insurance Portability and Accountability Act
ICD-10-CM	International Classification of Diseases, Clinical Modification, 10^th Revision
ICN	Internal control number. Carrier internal control number used for tracking purposes.
Jurisdiction	The defined geographic territory for which a carrier has the responsibility for processing claims.
Limiting charge	Charge limits imposed on the unassigned billed charges of all covered services of nonparticipating physicians.
MAC	Medicare Administrative Contractor: A private health care insurer that has been awarded geographic jurisdiction to process Medicare Part A and Part B medical claims, or DME claims for fee-for-service beneficiaries.
MBI	Medicare Beneficiary Identifier
MCS	Multi-Carrier System
Medicare Part A	Medicare coverage to assist in paying for services rendered by hospital, post-hospital, and other covered facilities.
Medicare Part B	Medicare coverage to assist in paying for services rendered by physicians, providers and suppliers.
Medigap policy	Private health insurance designed to supplement Medicare.
Modifier	A code or number that provides the means by which the reporting provider can indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code.
MREP	Medicare Remit Easy Payment. An electronic remittance software application to view and print the Remittance Advice.
MSN	Medicare Summary Notice. The notice a beneficiary receives when a disposition has been made on a claim submitted on his/her behalf.
MSP	Medicare Secondary Payer. The Medicare term for the coordination of benefits on behalf of a beneficiary, i.e., the determination of which insurance has primary/secondary responsibility for claim payments.
NCCI	A national policy implementation developed for Part B to control improper or incorrect coding practices on Medicare claims.
Nonassigned claim	A claim that directs payment to the beneficiary. Only a nonparticipating provider may elect to submit a nonassigned claim; participating providers must submit assigned claims, and the payment must go to the provider.
Nonparticipating provider	A provider who does not contractually agree to accept assignment on all covered Medicare claims, but may agree to accept assignment on a claim by claim basis.
NPI	National Provider Identifier. This unique number replaces the Provider Identification Number for Providers. Covered entities under HIPAA are required by regulation to use NPIs to identify health care providers in HIPAA standard transactions.
NSC	National Supplier Clearinghouse. An entity issuing DMEPOS supplier numbers so that physicians and suppliers can receive Medicare reimbursement. Also maintains a DMEPOS supplier national file.
Participating provider	A provider who contractually agrees to accept assignment on all covered Medicare claims.
PECOS	Provider Enrollment, Chain of Ownership System
PTAN	Provider Transaction Access Number
PPTN	Professional Provider Telecommunications Network. A software application to check beneficiary eligibility and claim status.
Reason/Remark codes	Information codes found on the Standard Paper Remittance that explain and instruct the providers regarding claim payments or denials, appeal rights, or re-submissions.
Reconsideration	Process of providing a provider an opportunity to appeal if he/she remains dissatisfied after the redetermination.
Redetermination	The first level of appeal when a provider disagrees with a claim denial.
SNF	Skilled nursing facility
SPR	Standard paper remittance. The standard paper remittance the provider receives to indicate action taken on the claim.
SSA	Social Security Administration
Supplemental Health Insurance	Private health insurance coverage designed to financially supplement some of the payment gaps in Medicare.
TPA	Third party administrator—a contractor to CMS and other partners for the purpose of exchanging adjudicated Medicare claims for secondary liability determination.
TPE	Targeted probe and educate

Reviewed 10/15/2024