ADA - American Dental Association
Dental procedure codes portion of HCPCS and standard dental claim form have been approved by this organization

AFDC - Aid to Families with Dependent Children
Categorical eligibility category prior to implementation on TANF

AHIP - AIDS Health Insurance Program

AHRH- At Home Residential Habilitation

ARU - Audio Response Unit
An interactive dial-in voice response unit accessed by digital phone and utilized by providers to verify Medicaid eligibility and conditions of coverage. The ARU is also referred to as a Voice Response Unit, Automatic Voice Response and Interactive Voice Response. Information about verifying eligibility for Medicaid Clients can be found in the MEVS Provider Manual in the Provider Manuals section of this website.

ATC - Alcohol Treatment Center

Auto-Assignment
The process by which the WMS automatically assigns a managed care recipient to a managed care provider if the recipient does not select a provider within a specified time frame

AVRS - Automated Voice Response System
See Audio Response Unit

AWP - Average Wholesale Price used for drug pricing

BENDEX - Beneficiary Data Exchange
A file containing data from CMS regarding persons receiving Medicare benefits from the Social Security Administration

BOEE- Bureau of Environmental Exposure

Buy-In
A procedure whereby the State pays a monthly premium to the Social Security Administration on behalf of eligible Medical Assistance recipients, enrolling them in the Medicare Part A and/or Part B Program

CASE - Computer-Aided Software Engineering
Software development tool

CCF - Claim Correction Form
Generated by eMedNY and sent to the provider that submitted the claim for correction of selected information and resubmitted by the provider with additional or corrected information

CCN - Claim Control Number
See Transaction Control Number

CEDR - Client Eligibility Data Repository

CEP - Claims and Encounter Processing
System component that handles the editing, pricing, and adjudication of claims submitted to the eMedNY system

CFOI- Census of Fatal Occupational Injuries

CFR - Code of Federal Regulations
Federal regulations that define Medicaid rules and regulations

CG - Companion Guide
A Companion Guides is a written specification used by Trading Partners to create eMedNY claims and requests and to interpret eMedNY responses to multiple transactions. The New York State Department of Health (NYS DOH) has provided Medicaid Companion Documents to assist Providers, Clearinghouses and all Covered Entities in preparing HIPAA compliant transactions. NYS DOH has focused primarily on the rules and policies regulating the submission of Medicaid data that are provided within each Companion Guide document. NYS DOH has provided the information as a tool to make the Provider’s job easier in preparing electronic transactions in a HIPAA compliant manner. Companion Guides are located here.

CHP - Child Health Plus
This is ahealth insurance plan for children. Depending on the family’s income, a child may be eligible to join either Child Health Plus A (formerly Children’s Medicaid) or Child Health Plus B. Both Child Health Plus A and B are available through many providers throughout the state.

CIDP- Chronic Illness Demonstration Project

Claim
A provider's request for reimbursement of Medicaid-covered services, submitted to the department using approved claim forms or approved electronic submittal media

CLIA - Clinical Laboratory Improvement Amendments
A federally mandated set of certification criteria and data collection monitoring system designed to ensure the proper certification of clinical laboratories

CMS - Centers for Medicare and Medicaid Services
The Federal agency that oversees the Medicare and Medicaid programs.

COS - Category of Service
A service or group of services which the provider is eligible to render under the Medicaid program. Provider services are categorized for processing and reporting purposes. COS is assigned by New York State at the time of enrollment.

Covered Services
Mandatory medical services required by HCFA and optional medical services approved by the State for which the enrolled provider will be reimbursed for services provided to eligible Medicaid recipients

CPAS - Claims Processing Assessment System
Manual or automated claims analysis tool used by the Department of Health for quality control reviews

CRCS - Capitation Rate Calculation Sheet

CRN - Claim Reference Number
See Transaction Control Number

DAC - Disabled Adult Child

DACE- Date Active Care Ended

DEA - Drug Enforcement Agency

DEAA - Data Exchange Application & Agreement

DEA Number
Number assigned to prescribing providers (e.g. physicians) as a part of controlled substances management

DED - Data Element Dictionary

DFA - Department of Family Assistance
Responsible for overseeing the Local Departments of Social Services (LDSS) in the determination of eligibility of Medicaid clients

DHHS - Department of Health and Human Services
Responsible for the administration of Medicaid at the Federal level through the Centers for Medicare & Medicaid Services (CMS).

DIS - Detailed Implementation Schedule
Document submitted to the CMS regional office at the start of the eMedNY Implementation Phase to document the project plan, and updated periodically to keep CMS informed of progress.

DME - Durable Medical Equipment
Equipment such as wheelchairs, hospital beds, and other non-disposable medically necessary equipment

DOCS - Department of Correctional Services

DOH - Department of Health
New York State agency responsible for the administration of the Medicaid program at the state level

DRG - Diagnosis-Related Grouping
Used as a basis of payment for some hospital inpatient stays

Drug Rebate
Program authorized by the Omnibus Budget Reconciliation Act of 1990 (OBRA-90) in which legend drug manufacturers, or labelers, enter into an agreement with DHHS to provide financial rebates to states based on the dollar amount of their drugs reimbursed by the Medicaid program

DSH - Disproportionate Share Hospital
Reimbursement to selected hospitals to compensate for health care services that have been provided to members of New York's indigent population

DSMO - Designated Standards Maintenance Organizations
A group of organizations managing HIPAA standard change requests

DSS - Decision Support System
Data warehouse component

DSS - Department of Social Services
New York State agency previously responsible for overseeing the Local Departments of Social Services (LDSS) in the determination of eligibility of Medicaid clients; DSS has been superseded by the Department of Family Assistance (DFA), which has been reorganized into several components

DUR - Drug Utilization Review
Federally mandated, Medicaid-specific prospective and retrospective drug utilization review system and all related services and activities necessary to meet all Federal and State DUR requirements

DVS - Dispensing Validation System

EAC - Estimated Acquisition Cost
Federal pricing requirements for drugs

EBT - Electronic Benefits Transfer

EC - Electronic Commerce (E-Commerce)
Term applied to group a variety of electronic business components of the Medicaid program. Included in electronic commerce are 1) electronic banking, including Electronic Funds Transfer (EFT), Electronic Benefits Transfer (EBT), and cash management systems; 2) electronic transaction processing, including claims, encounter data, and MEVS transactions; and 3) Internet on-line services and information publishing

ECC/ECCA - Electronic Claims Capture (and Adjudication)
Refers to the direct transmission of electronic claims over phone lines to the MEVS; ECC provides the ability to utilize Point-of-Service devices and PCs used for eligibility verification, claims capture, application of ProDUR, prepayment editing, and response to and acceptance of claims submitted on-line

ECM - Electronic Claims Management

ECS - Electronic Claims Submission
Submission of claims in electronic format rather than paper

EDI - Electronic Data Interchange

EEDSS - Electronic Eligibility Decision Support System

EFT - Electronic Funds Transfer
Paying providers for approved claims via electronic transfer of funds from the State directly to an account specified by the provider.

EMC - Electronic Media Claims
Claims submitted in electronic format rather than paper

EOB - Explanation of Benefits
An explanation of denied or reduced payment included on a remittance advice

EOMB - Explanation of Medical Benefits
A form provided by eMedNY and then sent to clients; the EOMB details the payment/denial of claims submitted by providers for services provided to the recipient

EOP - Explanation of Payment
Provides a description of reimbursement activity on the remittance advice

EOS - Enterprise Output System

ePACES - Electronic Provider Assisted Claim Entry System
A web-based program that allows enrolled New York Medicaid providers to submit and receive responses for HIPAA-compliant claims, eligibility requests, prior approval requests and claim status requests. Detailed information about ePACES can be found in the NYHIPAADESK section of this website. Click on ePACES General Information and Enrollment.

EPIC - Elderly Pharmaceutical Insurance Coverage
A New York State-funded program to cover prescriptions for the elderly population with limited income earnings.

EPSDT - Early and Periodic Screening, Diagnosis and Treatment
Also known as C/THP in New York; a program for Medicaid-eligible recipients under the age of twenty-one (21); EPSDT offers free preventive health care services such as screenings, well-child visits, and immunizations; if medical problems are discovered, the recipient is referred for further treatment.

ETIN - Electronic Transmitter Identification Number
This was formerly known as TSN. An ETIN is a number required for a provider to submit electronic claims to Medicaid. The ETIN is assigned by eMedNY and is linked to a provider’s Medicaid ID number by a Certification Statement. Both forms are available on this website. Look in the Featured Links Section and click on Provider Enrollment Forms.

FA - Fiscal Agent
A contractor who operates a claims processing system and pays providers on behalf of the State

FAQ - Frequently Asked Questions
A list of common questions and associated answers on a specified topic.

FDR - First Data Resources

FEIN - Federal Employer Identification Number
A number assigned to businesses by the Federal government.

FFP - Federal Financial Participation
Percentage of State expenditures to be reimbursed to the State by the Federal government for medical services and administrative costs ofthe Medicaid program

FHP - Family Health Plus
Family Health Plus is a public health insurance program for adults between the ages of 19 and 64 who do not have health insurance - either on their own or through their employers - but have income or resources too high to qualify for Medicaid. Family Health Plus is available to single adults, couples without children, and parents with limited income who are residents of New York State and are United States citizens or fall under one of many immigration categories.

FIPS - Federal Information Processing Standards

Fiscal Year - Federal
Operational year defined as October 1 through September 30

Fiscal Year - State
Operational year defined as April 1 through March 31

FQHC - Federally Qualified Health Center

Geocoding
Code structure used by the Geographic Information System to accumulate data by geographic locations

GIS - Geographic Information System
Commercial software which uses Geocoding to display data in map format

GUI - Graphical User Interface

HCBS - Home and Community-Based Services
Federal category of Medicaid services and waiver programs, established by Section 2176 of the Social Security Act, that includes adult day care, respite care, homemaker services, training in activities of daily living skills, and services not normally covered by Medicaid; these services are provided to disabled and aged recipients to allow them to live in the community and avoid being placed in an institution

HCFA - Health Care Financing Administration
Federal agency that oversees the Medicaid and Medicare programs

HCFA-1500
HCFA-approved standardized claim form used to bill professional services

HCPCS - HCFA Common Procedure Coding System
Uniform health care procedural coding system approved for use by HCFA; includes all subsequent editions and revisions thereof

HIC - Health Insurance Claim number
Number used to identify Medicare beneficiaries

HID - Health Information Designs
Responsible for the current Retrospective Drug Utilization Review conducted for NYSDOH

HIPAA - Health Insurance Portability and Accountability Act of 1996

HIV-EFP HIV Enhanced Fee Program
The New York State Department of Health, AIDS Institute sponsors a program, which pays enhanced Medicaid fees for qualified primary care physicians and specialists who provide services to persons with Human Immunodeficiency Virus (HIV) disease. The Department invites interested physicians, who meet certain eligibility and practice requirements, to apply to participate in the HIV Enhanced Fee for Physicians Program (HIV-EFP). In an effort to expand the network of HIV primary care providers, the NYSDOH is offering qualified, office-based physicians enhanced Medicaid reimbursement for HIV primary care services through the HIV-EFP program. To enroll in the HIV-EFP visit the Provider Enrollment Forms section of this website. Click on the HIV Enhanced Fee Payment.

HMO - Health Maintenance Organization

HSASC - Human Services Application Service Center

ICD-9-CM - International Classification of Diseases, 9^th Revision, Clinical Modification
ICD-9-CM codes are standardized diagnosis codes used on claims submitted by providers

ICF/MR - Intermediate Care Facility for the Mentally Retarded
ICFs/MR provide residential care treatment for Medicaid-eligible, mentally retarded individuals

IMD - Institutions for Mental Disease

IOC - Inspection of Care
Provides a review of residents in psychiatric hospitals and ICFs/MR; review process serves as a mechanism to ensure the health and welfare of institutionalized residents

IREF - Interim Recipient Eligibility File
A system operated on the HSASC data center to gather client-related data together to transmit to eMedNY and MEVS

ITF - Integrated Test Facility
A copy of the production version of eMedNY used for testing maintenance and modification changes prior to implementation of changes in the "production" system.

LDOH - Local Departments of Health
Local district entities responsible for implementing health programs at the local level

LDSS - Local Departments of Social Services
Local district entities responsible for Medicaid eligibility determination and for performing a number of Medicaid functions

LIF - Low Income Families program
New York State's TANF program

LOC - Level of Care

Local District
New York State local entities - There are fifty-seven (57) Upstate local districts, corresponding to the Upstate counties; there is one (1) local district comprising New York City and environs; the local districts are responsible for one-half of the State share of Title XIX expenditures

Lock-In
Restriction of a recipient to particular providers, as determined necessary by the State

LTC - Long-Term Care
Facilities that provide long-term residential care to recipients

MAC - Maximum Allowable Charge
The maximum allowable charge for drugs specified by the Federal government

MARS - Management and Administrative Reporting Subsystem
A federally-mandated comprehensive reporting module of eMedNY, including data and reports as specified by Federal requirements

MC - Managed Care

MCE - Managed Care Enrollment

MCO - Managed Care Organization

MEDS - Medicaid Encounter Data System

MEVS - Medicaid Eligibility Verification System
Major component of the New York Medicaid system which performs certain automated functions, including eligibility verification, service authorizations, prospective DUR, and managed care enrollment

MITA - Medicaid Information Technology Architecture

MEQC - Medicaid Eligibility Quality Control

MMTP - Methadone Maintenance Treatment Program
The goal of methadone maintenance treatment is to reduce illegal heroin use and the crime, death, and disease associated with heroin addiction. Methadone can be used to detoxify heroin addicts, but most heroin addicts who detox—using methadone or any other method—return to heroin use. The goal is to reduce and even eliminate heroin use among addicts by stabilizing them on methadone for as long as is necessary to help them avoid returning to previous patterns of drug use. The benefits of this treatment have been established by hundreds of scientific studies, and there are almost no negative health consequences of long-term methadone treatment, even when it continues for twenty or thirty years.

MOAS - Medicaid Override Application System

MOE - Model Office Environment
The system testing and quality assurance environment used for testing functionality and compliance of eMedNY-supported software across a broad spectrum of supported user configurations.

MOMS - Medicaid Obstetrical and Maternal Services Program
The MOMS program provides pregnancy services (medical and health supportive) in areas of the state where Prenatal Care Assistance Program (PCAP) health centers are not located. Medical services are provided in private physicians’ offices. Health Supportive Services (HSS) are provided by DOH approved providers. HSS includes the following: nutrition and psychosocial services, health education, HIV counseling and testing, and assistance with the Medicaid and WIC (Women, Infants, and Children) applications. All women enrolled in MOMS receive complete pregnancy care and can enter either by going through a MOMS physician or HSS provider.

NCPDP - National Council for Prescription Drug Programs

NDC - National Drug Code
A generally accepted system for the identification of prescription and non-prescription drugs available in the United States, including all subsequent editions, revisions, additions and preiodic updates

NPI - National Provider Identifier
Identification number

NSF - National Standard Format

NYT - New York Telecommunications network
A statewide New York telecommunications network backbone

OASAS - Office of Alcoholism and Substance Abuse Services

OLTP - Online Transaction Processing

OMC - Office of Managed Care
The office within the Department of Health responsible for the administration of the Managed Care program in the State of New York

OMH - Office of Mental Health

OMM - Office of Medicaid Management
The office within the Department of Health responsible for the administration of the Medicaid program in the State of New York

OMR/DD - Office of Mental Retardation and Developmental Disabilties

OSC - Office of the State Comptroller

PA - Prior Authorization / Prior Approval
Refers to the designated Medicaid services that require providers to request approval of certain types or amounts of services from the State prior to the provision of services; PAs are reviewed by the State for medical necessity, reasonableness, and other criteria

PASRR - Pre-Admission Screening and Resident Review
Refers to a set of long-term care resident screening and evaluation services, payable by the Medicaid program, that was authorized by the Omnibus Budget and Reconciliation Act of 1987

PBX - Public Branch Extension

PCP - Prepaid Capitation Plan
PCP means a Prepaid Capitation Plan (Medicaid managed care plan). There are several different types of Medicaid managed care plans, HMOs, PHSPs, HIV-SNPs, and PCMPs. These entities are responsible for providing or arranging for most medical services needed by a Medicaid recipient enrolled in the managed care plan.

HMOs, PHSPs and HIV-SNPs provide a comprehensive range of services that includes most Medicaid services. The services covered by the managed care plan are defined by the contract between the managed care plan and the State. Recipients get services not covered by the managed care plan through Medicaid fee-for-service. Generally, claims for covered services are paid for by the managed care plan, except when the recipient is enrolled in a PCMP.

When a recipient is enrolled in a PCMP, claims for covered services, other than primary care, are paid for by Medicaid fee-for-service with an appropriate referral from the PCP. Claims must have the referring ID of the primary care practitioner on the claim, or the service provider will not be paid.

PCP - Primary Care Provider
Primary Care Providers are qualified physicians, or certified nurse practitioners which provide primary care services and coordinate access to other medically necessary services in managed care plans. For more information on Medicaid Managed Care, click on NYHIPAADESK and select Provider Training Materials.

PDCS - Prescription Drug Card System

PDF - Portable Document Format

PDN- Private Duty Nurse

Post and Clear
A New York Medicaid process by which ordering/prescribing providers can authorize laboratory, drugs, or other services at the time of an eligibility verification query to the MEVS. A service authorization is generated which permits the laboratory, pharmacy, or other claim to be paid.

PPAC - Preferred Physician and Children Program
Physicians participating in PPAC receive increased Medicaid fees for visits provided to Medicaid recipients less than 21 years of age. PPAC helps to ensure these recipients’ access to private practice care in New York State. The fee structure for all visits incorporates a regional adjustment for upstate and downstate. The counties considered downstate for this program are Bronx, Kings, Queens, New York, Richmond, Nassau, Putnam, Rockland, Suffolk, and Westchester. To enroll in the PPAC Program visit the Provider Enrollment Forms section of this website. Click on the Preferred Physician and Children’s Program (PPAC) enrollment application.

PPO - Preferred Provider Organization

PRO - Peer Review Organization

ProDUR - Prospective Drug Utilization Review
The federally-mandated, Medicaid-specific prospective drug utilization review system and all related services and activities necessary to meet all Federal ProDUR requirements and those of the State of New York.

QDWI - Qualified Disabled Working Individual
A Federal category of Medicaid eligibility for disabled individuals who have income less than two hundred percent (200%) of the Federal poverty level; Medicaid benefits cover payment of the Medicaid Part A premium

QMB - Qualified Medicare Beneficiary
A Federal category of Medicaid eligibility for aged, blind, or disabled individuals who are entitled to Medicare Part A and who have income less than one hundred percent (100%) of the Federal poverty level and assets less than twice the SSI asset limit; Medicaid benefits include payment of Medicare premiums, coinsurance, and deductibles

RA - Remittance Advice
A summary of payments produced by eMedNY along with provider reimbursement; RAs are sent to providers along with checks or EFT

RBRVS - Resource-Based Relative Value Scale
A reimbursement methodology used to calculate payment for physician, dental, and other practitioners

RetroDUR - Retrospective Drug Utilization Review
A series of post-payment analytical reports which evaluate the use of drugs

RJE - Remote Job Entry

RSD - Roger Software Development

SDX - State Data Exchange system
The Social Security Administration's method of transferring SSA entitlement information to the State

SED - New York State Education Department

SERMA - Services/Medical Assistance Interface
Part of the Managed Care Readiness project

SLMB - Specified Low Income Medicare Beneficiary
A Federal category of Medicaid eligibility for aged, blind, or disabled individuals with income between one hundred percent (100%) and one hundred twenty percent (120%) of the Federal poverty level and assets less than twice the SSI asset level; Medicaid benefits include payment of the Medicare Part B premium

SNIP - Strategic National Implementation Process
A group engaged in an industry-wide process to improve healthcare standards

SPARCS - Statewide Planning and Research Cooperative System

SSA - Social Security Administration

SSI - Supplementary Security Income
The Federal supplemental security program that providers cash assistance to low-income aged, blind, and disabled persons

State
The State of New York and any of its departments or agencies and public agencies

SUM - Service Utilization Management
The eMedNY system component which provides the capability to control services requiring prior approval

SUR - Surveillance and Utilization Review
Refers to system functions and activities, mandated by CMS, which are necessary to maintain complete and continuous compliance with CMS regulatory requirements for SUR; SPR requirements for SUR include statistical analysis; exception processing; provider and recipient profiling; retrospective detection of payments and/or utilization inconsistent with State or Federal program policies and/or medical necessity standards; retrospective detection of fraud and abuse by providers or recipients; sophisticated data and claim sampling, analysis, and reporting; general access and processing features; and general reporting and output.

TANF - Temporary Assistance for Needy Families
Replacement program for Aid to Families with Dependent Children

TCN - Transaction Control Number
Transaction Control Number is a 16-digit number assigned to a claim during processing and is needed to adjust or void a previously paid claim. The TCN can be found on the provider’s remittance statement.

TMS - Terminal Management System

TOA - Threshold Override Application
TOAs can be submitted to increase the number of services a patient can receive or to obtain an exemption from the UT Service Authorization Program, depending on the patient's medical needs.

Please note that increases in service limits may only be requested for the recipient's current benefit year. (A benefit year is a 12 month period which usually begins the month in which the recipient becomes Medicaid eligible.) For example, if a recipient's benefit year begins in September (month 09), and the increased limit request is made after September, the provider may submit a TOA to request an increase only for dates occurring after September, but not for dates of service prior to September. Detailed information about the UT Program can be found in the NYHIPAADESK section of this website, Click on Provider Training Materials.

TPR - Third-Party Resource

TSN - Transmission Supplier Number

UB-04
Standard claim form used to bill hospital inpatient and outpatient services; paper equivalent of the Version 4 electronic format used in New York State

UCC - Usual and Customary Charge

UT - Utilization Threshold
The Utilization Threshold (UT) program monitors the number of services a Medicaid recipient receives in a benefit year. A benefit year is a 12-month period, which begins the month in which the recipient becomes Medicaid eligible. A post payment review is performed for trends or patterns that require further attention.

VAN - Value-Added Network

VPN - Virtual Private Network

WEDI - Workgroup for Electronic Data Interchange
A group of individuals focused on improving healthcare through information exchange and management using electronic commerce as the vehicle

WMS - Welfare Management System

WPC - Washington Publishing Company
Responsible for the publication of all Healthcare Transactions created from X12's Insurance subcommittee, X12N

X12
X12 is the DSMO (Designated Standards Maintenance Organization) named as author of all X12N Health Care Transactions under HIPAA.