C/Save -A tape created by the Social Security Administration each year containing SSI terminations for the previous three years. It is mandated by the Lynch v. Rank lawsuit, which requires Medicaid agencies to notify those terminated from SSI to apply for Medicaid.
Call Center -A physical location where calls are received, usually in high volume.
Call Center Management System -A centralized system to record, track, and monitor communications with providers, beneficiaries, and other external entities, including toll- free access for providers and beneficiaries.
Capitated Service -Any Medicaid-covered service for which the contractor receives capitation payment.
Capitation -A contractual arrangement through which a health plan or other entity agrees to provide specified health care services to enrollees for a specified prospective payment per member (beneficiary), per month. Usually covers all services rendered on behalf of the capitated recipient, although partial capitation may exclude specialty services.
Capitation Rate- The amount paid per member (beneficiary), per month for services provided at risk.
Case Management -A health care method in which medical, social and other services for a beneficiary are coordinated by one entity.
Case Manager -A person designated as the coordinator of resources for assigned beneficiaries to efficiently and effectively coordinate care.
Case-Mix Reimbursement Project -A project in Mississippi to develop a reimbursement plan for nursing facilities to appropriately compensate for the care required based on the residents' needs.
Categorically Needy -The term that identifies those aged, blind or disabled individuals or families who meet Medicaid eligibility criteria and who meet the financial limitation requirements for TANF, SSI or optional State financial support.
Certification -A review by CMS of an operational MMIS in response to a State’s request for 75 percent FFP to ensure that all legal and operational requirements are met by the system and its components.
Certification Date -An effective date specified in a written approval notice from CMS to the State when 75 percent FFP is authorized for the administrative costs of an MMIS.
Claim -A request for payment filed with the Fiscal Agent, on a form prescribed by DOM and the Fiscal Agent, by a certified Medicaid provider for Medicaid-covered medical and medically related services rendered on behalf of an eligible Medicaid beneficiary.
Claim Detail -Specifies basic data about the claim, such as monetary amount, service location, statement dates, etc. Also pertains to MMIS produced reports displaying details of adjudicated claim history for selected providers and/or beneficiaries, or based on other selection criteria
Claim Line -A line item of a document or electronic media claim which bills for a specific service(s) for a single beneficiary from a single provider.
Claim Type -The classification of a claim by origin or type of service provided to a beneficiary.
Clawback Also called "phasedown" - Mandatory State payments to the Federal government to help finance the Medicare Part D benefit for dual eligibles. The size of the state´s "clawback" payment for any given month will depend on 3 factors: 1. A per capita estimate of the amount the state otherwise would have spent on Medicaid prescription drugs for dual eligibles 2. The number of dual eligibles enrolled in a Part D plan. 3. A "takeback" factor set at 90% in 2006, declining to 75% for 2015 and later years.
Clean Claim -An error-free claim or an adjustment which was originally received by the Contractor can be processed without obtaining additional information or substantiation from the provider of service or the Division.
CMS-1500 -The CMS-1500 form is the standard claim form used by a non- institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies. The claim form used by the DOM to file for services performed by most practitioners.
CMS-2082- The CMS-(formerly HCFA-)2082 is an annual hard-copy report designed to collect State-reported statistical summary data on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through September 30). States summarize and report the data processed through their own Medicaid claims processing and payment operations, unless they opt to participate in the Medicaid Statistical Information System (MSIS) project.
Coinsurance -An arrangement by which an insurance plan, Medicare, Medicaid or other third party share the cost of medical expenses.
Confidentiality -Has been defined by the International Organization for Standardization (ISO) in ISO-17799 as "ensuring that information is accessible only to those authorized to have access" and is one of the cornerstones of information security. All reports, files, information, data, tapes and other documents provided to and prepared, developed, or assembled by the Contractor shall be kept confidential in accordance with Federal and State laws, rules and regulations and shall not be made available to any individual or organization by the Contractor without prior written approval of the DOM.
CONNECT NHIN -Gateway Open Source Implementation of NHIN Exchange.
https://www.connectopensource.org/
Contract -The written, signed agreement resulting from this RFP for operation of the MES.
Contract Administrator -State-employed staff person designated to coordinate and monitor the activities of the contract and to resolve questions and perform other functions, as necessary, to ensure the contract is appropriately administered.
Contract Amendment -Any written alteration in the specifications, delivery point, rate of delivery, contract period, price, quantity, or other contract provisions of any existing contract, whether accomplished by unilateral action in accordance with a contract provision, or by mutual action of the parties to the contract; it shall include bilateral actions, such as change orders, administrative changes, notices of termination, and notices of the exercise of a contract option.
Contractor -Any entity that enters into a contract with DOM to provide the services or manage the delivery of services outlined in this RFP.
CORE Phase II Certified -Certification for HIPAA EDI Transaction Types
Corrective Action Plan -Has the meaning set forth in the Statement of Work in this RFP.
Cost Avoidance -A term describing procedures or systems of ensuring that the beneficiary’s known other non-Medicaid health insurance resources were pursued prior to payment by Medicaid. MMIS typically has edits that deny or pend a claim, unless there is evidence that the claim had already been submitted to these entities.
Cost Settlement -An auditing process by which interim claims payments to cost based providers are adjusted yearly to reflect actual costs incurred.
Covered Services -Services and supplies for which Medicaid will reimburse the provider.
Credit -A health care claim transaction which has the effect of reversing a previously processed claim that has a corresponding original claim transaction.
Crossover Claim -A claim for services rendered to a beneficiary eligible for benefits under both Medicaid and Medicare programs. Medicare benefits must be processed prior to Medicaid benefits, so these claims are initially adjudicated by the Medicare intermediary or carrier.
Customer Service Representative -A general term for someone who handles telephone calls in a call or contact center.
Cutover -The date on which the successful bidder begins full and complete operation of the MMIS.
