Medical Assistance Programs Dictionary

Use this page to find definitions/descriptions of acronyms, words, and terms that are frequently used within the Office of Medical Assistance Programs.

Acronym/Word/TermDefinition/Description
AAAArea Agency on Aging - The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities.
ACCESS CardMedical Assistance Identification Card - The Pennsylvania ACCESS card is issued to individuals for Medical Assistance benefits. The card is one of the methods that may be used by Medical Assistance providers to verify an MA consumer’s eligibility for medical services through the Eligibility Verification System (see EVS).
ADAAmericans with Disabilities Act
ADAPAIDS Drug Assistance Program (see SBPB)
AIDSAcquired Immunodeficiency Syndrome
Alert(Remittance Advice Alert) – a special notice that is sent to Medical Assistance providers with their remittance advices to relay various information to them (important messages, reminders about billing procedures, etc.)
Alternate Payment NameThe name of the individual that the eligible Medical Assistance consumer has appointed to transact their benefits.
APDAdvance Planning Document
AURAutomated Utilization Review
BDCMBureau of Data and Claims Management
Benefit ConsultantAn individual or group that assists Medical Assistance recipients with choosing a physical health managed care plan, selecting a primary care provider, and obtaining information on behavioral health services.
BFFSPBureau of Fee for Service Programs
BHBehavioral Health (services) – Commonly known as mental health and/or drug and alcohol services.
BH-MCOBehavioral Health Managed Care Organization – An entity directly operated by the county government or licensed by the Commonwealth as a Health Maintenance Organization or risk-assuming Preferred Provider Organization which manages the purchase and provision of behavioral health services.
BMCOBureau of Managed Care Operations
BPAPBureau of Policy, Analysis and Planning
BPIBureau of Program Integrity
Bulletin(Medical Assistance Bulletin) – a formal mailing to Medical Assistance providers to relay various information to them (change in MA policy, change in billing procedures, fee schedule changes, etc.) Bulletin Search
CAOCounty Assistance Offices -- CAOs administers all the benefit programs, including Medical Assistance, at the local level. Department staff in these offices perform necessary functions such as determining and maintaining Medical Assistance recipient eligibility.
CapitationA fee the Department of Human Services pays periodically to a contractor for each Medical Assistance recipient enrolled under a contract for the provision of medical services, whether or not the Medical Assistance recipient receives services during the period covered by the fee.
CARCClaim Adjustment Reason Code
CDCCenters for Disease Control and Prevention
CFOChief Financial Officer
CFRCode of Federal Regulations
CHIPChildren's Health Insurance Program
Children in Substitute CareChildren who have been adjudicated dependent or delinquent and are in the legal custody of a public agency and/or under the jurisdiction of the juvenile court, and are living outside of their homes in any of the following settings: shelter homes, foster homes, group homes, supervised independent living, residential treatment facilities, and residential child care facilities.
CHRConcurrent Hospital Review
CISClient Information System – the Department’s automated file that contains demographic and eligibility information for all Medical Assistance recipients.
CMICase Mix Index - a number value score that describes the relative resource use for the average resident in each of the groups under the RUG-III classification system based on the assessed needs of the resident
CMICCentral Management Information Center
CMSCenters for Medicare and Medicaid Services
COBCoordination of Benefits
COBRACongressional (or Consolidated) Omnibus Budget Reconciliation Act
COLACost of Living Adjustment
ContractorThe successful bidder or its successor approved by the Department.
CPT(Physician’s) Current Procedure Terminology
CRFCommunity Residential Facility
CRNClaim Reference Number – a 10-digit identification number assigned to every Medical Assistance claim or claim adjustment received by the Department for tracking purposes
CRNPCertified Registered Nurse Practitioner
CSPCommunity Support Program
DAPDisability Advocacy Program
DEADrug Enforcement Agency
Developmental DisabilityIntellectual Disability is the most prevalent of a broad spectrum of developmental disabilities. The term "developmental disability" means a severe, chronic disability of an individual that is:
* attributable to a mental or physical impairment or combination of mental or physical impairments;
* manifested before the individual attains age 22;
* likely to continue indefinitely;
* results in substantial functional limitations in three of more the following areas of life activity: self care; receptive and expressive language; learning; mobility; capacity for independent living; and economic self sufficiency.
* reflects the individual’s need for a combination and sequence of special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.
DHHSU.S. Department of Health and Human Services
DisabledAny person who has a physical or mental impairment that substantially limits one or more life activities (e.g. caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, learning, and working); or has a record of an impairment (has a history of, or has been misclassified as, having a mental or physical impairment) that substantially limits one or more major life activities; or is regarded as having an impairment.
DMEDurable Medical Equipment
DOHDepartment of Health
DOIDepartment of Insurance
DHSDepartment of Human Services
DRGDiagnostic Related Group
DRODomestic Relations Office
DSHDisproportionate Share
Dual EligibleAn individual who is eligible to receive services through both Medicare and Medicaid (Medical Assistance)
DURDrug Utilization Review
EBTElectronic Benefits Transfer
ECMElectronic Claims Management
EDIElectronic Data Interchange
EFTElectronic Funds Transfer
EINEmployer Identification Number
EMCElectronic Media Claims
EMSEmergency Medical Services
EOMBExplanation of Medical Benefits
EPSDTEarly and Periodic Screening, Diagnosis and Treatment
EREmergency Room
EVSEligibility Verification System
Facility MA CMIFacility Medical Assistance Case Mix Index - the arithmetic mean CMI for MA residents in the nursing facility for whom the Department paid an MA day of care on the picture date.
Family Planning ServicesContraceptive needs met through the provision of educational, medical, and social services. Services enable individuals voluntarily to determine family size, to space children, and to prevent or reduce the incidence of unplanned pregnancies. Services are made available without regard to marital status, age, sex, or parenthood.
FDAFood and Drug Administration
FFSFee-for-Service – payment on a per-service basis for health care services provided to Medical Assistance recipients
FQHCFederally Qualified Health Center
FYFiscal Year
GAGross Adjustment or General Assistance (depends on context used)
Gross Adjustment –
General Assistance - Assistance for persons not eligible for a Federal Category; usually adults without children that have a permanent or temporary disability that precludes employment. Must meet income and assets limits.
HBPHealthy Beginnings Plus
HC-L/CHealthChoices Lehigh/Capital – The mandatory Medical Assistance managed care program for the counties of Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York.
HCPCSHCFA Common Procedure Coding System
HC-SEHealthChoices Southeast – The mandatory Medical Assistance managed care program in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
HC-SWHealthChoices Southwest – The mandatory Medical Assistance managed care program for Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland counties.
HealthChoicesThe name of Pennsylvania’s 1915(b) waiver program to provide mandatory managed health care to Medical Assistance recipients.
HIPAAHealth Insurance Portability and Accountability Act
HEDISHealthplan Employer Data Information Set
HIPPHealth Insurance Premium Payback
HIVHuman Immunodeficiency Virus
HMOHealth Maintenance Organization – A public or private organization organized under state law that is a federally-qualified health maintenance organization or meets the State Plan’s definition of a health maintenance organization.
HPEHewlett Packard Enterprise - the claims processing contractor for the Pennsylvania Medical Assistance Program
ICFIntermediate Care Facility
ICF/MRIntermediate Care Facility for the Mentally Retarded
IEAPIndependent Enrollment and Assistance Program
IEVSIncome Eligibility Verification System
IFBInvitation for Bid
IGTIntergovernmental Transfer Agreement - the formal document that executes the transfer of funds or certification of funds to the Commonwealth by another unit of government within the Commonwealth in accordance with Section 1903 of the Social Security Act (42 U.S.C.A. subsection 1396b(w)(6)(A).
IRSInternal Revenue Service
ITInformation Technology
ITBInvitation to Bid
JCAHOJoint Commission for the Accreditation of Healthcare Organizations
JDCJuvenile Detention Center
LANLocal Area Network
LIHEAPLow Income Home Energy Assistance Program
LTLLong Term Living
LTCMSLong Term Care Management System
MAMedical Assistance
MAACMedical Assistance Advisory Committee
MACMaximum Allowed Cost
MAID (number)Medical Assistance Identification Number
MAMISMedical Assistance Management Information System
MANMetropolitan Area Network
MCOManaged Care Organization – An entity which manages the purchase and provision of physical or behavioral health services for eligible Medical Assistance recipients.
MDSMinimum Data Set - one of the three components of the federally designed Resident Assessment Instrument (RAI). The RAI includes the MDS, the Resident Assessment Protocols and Utilization Guidelines. The MDS is a minimum care of assessment items with definitions and coding categories needed to comprehensively assess a nursing facility resident.
MEDAMedical Eligibility Determination Automation
MFCUMedicaid Fraud Control Unit
MHMental Health
MMISMedicaid Management Information System
MQCMedicaid Quality Control
MSA (group)Metropolitan Statistical Area - a statistical standard classification designated and defined by the Federal Office of Management and Budget following a set of official published standards.
MSIMedical Services Invoice
NCPDPNational Council of Prescription Drug Programs
NCQANational Committee for Quality Assurance
NDCNational Drug Code
NECSNational Electronic Claims Submission
NFNursing Facility - a general nursing facility, county or hospital-based nursing facility, which is licensed by the Department of Health and enrolled in the Medical Assistance program.
NISNursing Information System - the comprehensive automated database of nursing facility, resident and fiscal information needed to operate the Pennsylvania Case-Mix Payment System.
NPDBNational Practitioner Data Bank
NPINational Provider Identifier
OBRAOmnibus Budget Reconciliation Act
OCDELOffice of Child Development and Early Learning
OCYFOffice of Children, Youth and Families
ODPOffice of Developmental Programs
OIMOffice of Income Maintenance
OLTLOffice of Long Term Living
OMAPOffice of Medical Assistance Programs
OMDOffice of the Medical Director
OMHSASOffice of Mental Health and Substance Abuse Services
OPTIONSCommunity Based Long Term Care
PAPrior Authorization
PACEPennsylvania Adoption Cooperative Effort
PACEPharmaceutical Assistance Contract for the Elderly
PACSESPennsylvania’s Child Support Enforcement System
PBMPharmacy Benefit Manager
PCPPrimary Care Provider – A specific medical services provider responsible for providing primary care services and locating, coordinating, and monitoring other medical care and rehabilitative services on behalf of a Medical Assistance recipient.
PDAPennsylvania Department of Aging
PEProgram Exception – Exception to the normal MA fee schedule or process for various reasons.
PERMPayment Error Rate Measurement
PHPhysical Health
PHC4Pennsylvania Healthcare Cost Containment Council
PH-MCOPhysical Health Managed Care Organization – A Commonwealth-licensed risk-bearing entity which has contracted with the Department of Human Services to manage the purchase and provision of physical health services to Medical Assistance recipients.
PMSPennsylvania Medical Society
POSPoint of Sale
POSNetPennsylvania Open Systems Network – The network that is used to access the Department’s computer system, and to send and receive files from the Department’s contractors. POSNet is an extended Ethernet LAN (Local Area Network). The selection of industry standard protocols means that the LAN capabilities can be extended statewide by using LANs, Metropolitan Area Networks (MANs), and Wide Area Networks (WANs).
PPSProspective Payment System - Medicare's version of our case-mix reimbursement system.
ProDURProspective Drug Utilization Review
PROMISe™Provider Reimbursement Operations and Management Information System
ProviderA person, firm, or corporation enrolled in the Pennsylvania Medical Assistance Program which provides services or supplies to Medical Assistance recipients.
PRRProgram Revision Request
PSRPlace of Service Review
QAQuality Assurance
QCQuality Control
QMQuality Management
QMBQualified Medicare Beneficiary
RARemittance Advice – an explanation containing the status of claims processed during a particular period for providers. Remittance Advices are mailed to providers on a weekly basis.
RecipientA person eligible to receive health-related services under the Medical Assistance Program in Pennsylvania.
RetroDURRetrospective Drug Utilization Review
RFPRequest for Proposal
RIDSResolution Image Display System
RNACRegistered Nurse Assessment Coordinator - an individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility, and who is responsible for coordinating and certifying completion of the resident assessment.
RRPRecipient Restriction Program
RTFResidential Treatment Facility
RUG-IIIResource Utilization Group Version III - a category-based resident classification system used to classify nursing facility residents into groups based on their characteristics and clinical needs.
SCSCState Civil Service Commission
SPBPSpecial Pharmaceutical Benefits Program - The SPBP is a unique program that provides specific HIV/AIDS drugs and several atypical antipsychotic drugs for low and moderate income individuals with a diagnosis of HIV/AIDS or schizophrenia. Medical Assistance clients with drug benefits through the regular fee-for-service program or MA Managed Care Organizations are NOT eligible for SPBP coverage. The HIV/AIDS piece of the program is usually known as AIDS Drug Assistance Program or ADAP in other states.
SPOCSingle Point of Contact
SSASocial Security Administration
SSISupplemental Security Income - Persons permanently disabled (must last at least 12 months) as determined by the Social Security Administration may qualify for this.
SSNSocial Security Number
STDSexually Transmitted Disease
SURSSurveillance and Utilization Reporting System - a computerized reporting system used to detect potential fraud and abuse of Medical Assistance providers and recipients.
TANFTemporary Assistance for Needy Families
TCMTargeted Case Management
TINTax Identification Number
Total Facility CMITotal Facility Case Mix Index - the arithmetic mean case mix index of all residents regardless of the resident's sources of funding.
TPLThird Party Liability
UB-92 (form)Unified Billing 1992 (form) – used for billing Pennsylvania Medical Assistance for Inpatient services
UMRUtilization Management Review - an audit conducted by the Department's medical and other professional personnel to monitor the accuracy and appropriateness of payments to nursing facilities to determine the necessity for continued stay of residents.
VTVoucher Transmittal
WANWide Area Network
WICWomen, Infants and Children (program)
YTDYear to Date