Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 3 - PAYMENT FOR MEDICAID SERVICES › Section 471-3-002 - DEFINITIONS

Current through June 17, 2024
002.01
ADJUDICATE.
To determine whether a claim or adjustment is to be paid or denied.
002.02
BALANCE
  BILLING.
Billing the Department or client any amount after a
  provider has agreed to accept a payment as payment in full.
002.03
CASUALTY
  INSURER.
An insurance policy which pays for medical care as a
  result of an accident, incident, injury, disability, or disease; for example,
  automobile insurance, homeowners insurance, commercial liability insurance,
  product liability insurance, workers compensation, etc.
002.04
CLAIM.
A
  request for payment for services rendered or supplied by a provider to a
  client.
002.05
CLEARINGHOUSE.
An entity which processes or facilitates the
  processing of information received from another entity in a nonstandard format
  or containing nonstandard data content into standard data elements or a
  standard transaction and receives a standard transaction from another entity
  and processes or facilitates the processing of health information into
  nonstandard or nonstandard data content for the receiving entity.
002.06
CLIENT ASSIGNMENT OF
  RIGHTS.
The client's action to assign to the Department his or her
  rights, and the rights of any other eligible individuals on whose behalf he or
  she has legal authority under state law to assign such rights, to medical
  support and to payment for medical care from any liable third party, except
  Part A and B of Medicare. Assignment of rights is accomplished by signing the
  Medicaid application.
002.07
DENIAL.
Non-payment of services or benefits by
  Nebraska Medicaid.
002.08
HEALTH INSURER.
Any group health plan, as defined in
  section 607(1) of the Employee Retirement Income Security Act of 1974, as
  amended in 1993, an entity offering a service benefit plan, or a health
  maintenance organization (HMO).
002.09
HEALTHCARE COMMON
  PROCEDURE CODING SYSTEM (HCPCS).
The system which contains the
  national codes adopted by the federal Secretary of Health and Human Services
  and includes American Medical Association's Current Procedural Terminology
  (CPT) Level I procedure codes and Level 2 procedure codes.
002.10
INDIAN.
An
  individual, defined at 25 United States Code (U.S.C.) sections 1603(c),
  1603(f), and 1679(b), or who has been determined eligible, as an Indian,
  pursuant to
  42 Code of Federal
  Regulations (C.F.R.) 136.12 or Title V of the
  Indian Health Care Improvement Act, to receive health care services from Indian
  Health Service, an Indian Tribe, Tribal Organization, Urban Indian
  Organization, or through referral under Contract Health Services.
002.11
INDIAN HEALTH CARE
  PROVIDER.
A health care program, including contract health
  services, operated by the Indian Health Service or by an Indian Tribe, Tribal
  Organization, or Urban Indian Organization as those terms are defined
  25
  U.S.C. 1603.
002.12
MEDICARE ADVANTAGE
  PLAN.
Coordinated care plans meeting Medicare C standards,
  including health maintenance organizations (HMO), Provider Sponsored
  Organizations (PSO), Preferred Providers Organizations (PPO), religious
  fraternal benefits plans, and other coordinated care plans. Individuals
  eligible for Medicare Part A and Part B may choose to enroll in a Medicare
  Advantage Plan instead of the traditional Medicare fee-for-service program.
  Part B only enrollees are ineligible.
002.13
MEDICAL
  SUPPORT.
The obligation of a non-custodial parent to provide
  health insurance or pay for medical care ordered by a court or administrative
  body established under state law.
002.14
MEDICARE AND MEDICAID
  DUALLY ELIGIBLE INDIVIDUAL.
Individuals dually eligible for
  Medicare and Medicaid during the same period of time.
002.15
MEDICARE PART
  A.
A federal program, created by the Social Security Act of 1965,
  to provide coverage of hospital, skilled nursing, and certain other services
  for Medicare beneficiaries.
002.16
MEDICARE PART B.
A federal program, created by the
  Social Security Act of 1965, to provide coverage of practitioner, durable
  medical equipment, supplies, and certain other services for Medicare
  beneficiaries.
002.17
MEDICARE PART D.
A federal program, also known as the
  Medicare prescription drug benefit. This voluntary program provides coverage of
  certain drugs, classes of drugs, or therapeutic categories of drugs and certain
  medical supplies or equipment for all Medicare beneficiaries, including those
  beneficiaries also eligible for Medicaid. Clients who are dually eligible for
  Medicare and Medicaid are automatically enrolled in Part D.
002.18
MEDICARE PART D
  PLAN.
An entity, approved by the Centers for Medicare and Medicaid
  Services, to provide coverage of Medicare Part D drugs and certain medical
  supplies for Medicare beneficiaries.
002.19
MEDICARE PART D
  DRUG.
Any drug, class of drugs, or therapeutic category of drugs
  which is not a Medicare Part D Excluded drug, regardless of formulary, prior
  approval, or tier status by the Part D Plan.
002.20
MEDICARE PART D EXCLUDED
  DRUG.
Any drug, class of drugs, or therapeutic category of drugs
  which is specifically excluded from coverage under the Medicare Modernization
  Act of 2003 and amendments to the act, or as defined by federal regulations
  implementing the Medicare Modernization Act.
002.21 MEDICARE PART D SUPPLIES OR EQUIPMENT.
  Insulin syringes, needles, alcohol swabs, gauze, and other products covered by
  Medicare Part D Plans.
002.22
NON-CUSTODIAL PARENT.
Parent who does not reside with
  a child but has a legal responsibility to provide court or administrative
  ordered medical support for the child.
002.23
PAY AND
  CHASE.
A recovery method in which Medicaid pays the total amount
  allowed under Nebraska Medicaid and then seeks to recover from liable third
  party resources.
002.24
PREFERRED PROVIDER ORGANIZATION (PPO).
Fee for service
  plan with an incentive to use network providers to provide care for the plan's
  subscribers. Patients may see physicians outside the network but at reduced
  payment rate. A copayment may be required on certain services.
002.25
PRIVATE
  INSURER.
This includes:
(A) Any
  commercial insurance company offering health or casualty insurance to
  individuals or groups, including both experience-related and indemnity
  contracts;
(B) Any profit or
  nonprofit prepaid plan offering either medical services or full or partial
  payment for the diagnosis and treatment of an injury, disease, or disability;
  and
(C) Any organization
  administering health or casualty insurance plans for professional associations,
  unions, fraternal groups, employer-employee benefit plans, and any similar
  organization offering these payments for services, including self-insured and
  self-funded plans, under section 607(1) of the Employee Retirement Income
  Security Act.