Last Modified: 1/14/2020
Location: FL, PR, USVI
Business: Part A, Part B
Below is a list of terms commonly used in the Medicare enrollment process:
• Accredited provider/supplier -- means a supplier that has been accredited by the Centers for Medicare & Medicaid Services (CMS)-designed accreditation organization.
• Advanced diagnostic imaging service -- means any of the following diagnostic services:
1. Magnetic Resonance Imaging (MRI)
2. Computed Tomography (CT)
3. Nuclear Medicine
4. Positron Emission Tomography (PET)
• Advanced Life Support, level 1 (ALS1) -- Transportation by ground ambulance vehicle, medically necessary supplies and services, and either an ALS assessment by an ALS personnel or the provision of at least one ALS intervention, refer to 42 CFR (Code of Federal Regulations) section 414.605.
• Advanced Life Support, level 2 (ALS2) -- Either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continues infusion, excluding crystalloid, hypotonic, isotonic and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate) or transportation, medically necessary supplies and services and at least one of the seven ALS procedures specified in 42 CFR 414.605.
• Air ambulance -- fixed wing and rotary wing. Air ambulance is furnished when the patient’s medical condition is such that transport by ground ambulance is not appropriate: one patient’s condition requires rapid transport to a treatment facility and second patient is inaccessible by ground or water vehicle.
• Applicant versus provider/supplier -- The provider is the entity furnishing the service, (e.g., the hospital, home health agency, etc.) The applicant is the business entity that the provider is set up as. For instance, suppose the provider is a hospital organized as a corporation. (That is, the hospital and the corporation are one in the same, operating under the same TIN). In this case, the hospital is the provider, and the corporation is the applicant.
• Applicant -- The individual (practitioner/supplier) or organization who is seeking enrollment into the Medicare program.
• Approve/Approval -- Means the enrolling provider or supplier has been determined to be eligible under Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges.
• Authorized Official -- Is an appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
• Bankruptcy -- When a provider/supplier files for protection in a Federal bankruptcy court, it may choose, with the permission of the court, to cease operations (chapter 7) or reorganize (Chapter 11). When a provider/supplier files under Chapter 7, it will liquidate its assets and cease operations and must notify the contractor of this fact. When the assets are sold to a different entity that entity must enroll with the contractor if it wishes to bill the Medicare program.
• Basic Life Support (BLS) – Ambulances must be staffed by at least two people – who meet the requirements of state and local laws where the services are being furnished and where at least one of whom must (1) be certified at a minimum as an emergency medical technician – basic (EMT-basic by the state or local authority where the services are being furnished and (2) be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle.
• Billing agency -- A company that the applicant contracts with to prepare, edit and/or submit claims on its behalf.
• Change of ownership (CHOW) -- Is defined in 42 CFR 489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law. In the case of a corporation, the term generally means the merger of the provider corporation into another corporation, or the consolidation of two or more corporations, resulting in the creation of a new corporation. The transfer of corporate stock or the merger of another corporation into the provider corporation does not constitute change of ownership.
• Certified Part A Provider/Supplier – Part A provider/supplier who is State approved based on Regional Office’s survey or certification unit. Providers/suppliers are approved or “certified” by Medicare if they’ve passed an inspection conducted by a state government agency.
• Certified Part B Provider/Supplier – Part B certified providers/suppliers include audiologist, ambulance service suppliers, Independent Clinical Labs (CLIAs), occupational therapist, physical therapist, speech language pathologist and mass immunization roster billers. Effective dates are based on Julian date of application (receipt date).
• CMS- approved accreditation organization means an accreditation organization designated by CMS to perform the accreditation functions specified.
• Contractor – Administers the Medicare program for the government agency.
• Coupon 8109 – (Internal Revenue Service) IRS document that is pre-printed with the tax identification number and legal business name.
• CP-575 -- IRS documents confirming the tax identification number and legal business name
• Coach – An individual who furnished Medicare Diabetes Prevention Program (MDPP) services on behalf of an MDPP supplier as an employee, contractor or volunteer.
• Community Setting – A location where the MDPP supplier furnishes MDPP serviced outside of their administrative locations in meeting location open to the public. A community setting is a location not primarily associated with the supplier where many activities occur, including but not limited to MDPP services. Community settings may include, for example, church basements or multipurpose rooms in recreation centers.
• Deactivate -- The provider or supplier’s billing privileges were stopped, but can be restored upon the submission of updated information.
• Delegated official -- An individual, delegated by the “Authorized Official,” with the authority to report changes and updates to the enrollment record. The delegated official must be an individual with an ownership or control interest in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of, the provider or supplier.
• Deny/Denial -- The enrolling provider or supplier has been determined to be ineligible to receive Medicare billing privileges for Medicare covered items or services provided to Medicare beneficiaries.
• Direct or indirect ownership -- The following example illustrates the difference between direct and indirect ownership: The supplier listed in Section 2 of the CMS 855B is an ambulance company that is wholly (100 percent) owned by Company A. Here, Company A is considered to be a direct owner of the supplier (the ambulance company), in that it actually owns the assets of the business. Now assume that Company B owns 100 percent of Company A. Company B is considered an indirect owner - but an owner, nevertheless - of the supplier. In other words, a direct owner has an actual ownership interest in the supplier, whereas an indirect owner has an ownership interest in an organization that owns the supplier.
• Divestiture -- The act of a provider/supplier selling off part or all of its assets, whether voluntarily or by court order. Whether or not a divestiture constitutes a change of ownership (CHOW) for a provider depends on the structure of the transaction.
• Eligible coach – An individual who CMS has screened and determined can provide MDPP services on behalf of an MDPP supplier.
• Enroll/Enrollment -- The process that Medicare uses to establish eligibility to submit claims for Medicare covered services and supplies. The process includes:
• Identification of a provider or supplier;
• Validation of the provider or supplier’s eligibility to provide items or services to Medicare beneficiaries;
• Identification and confirmation of the provider or supplier’s practice locations and owners; and,
• Granting the provider or supplier Medicare billing privileges
• Enrollment application -- A CMS-approved enrollment application or an electronic Medicare enrollment process approved by the Office of Management and Budget.
• CMS 855A -- Health Care Providers that will bill Medicare Administrative Contractors for Part A services -application to be completed by a provider (e.g., hospital).
• CMS 855B -- Health Care Suppliers -application to be completed by a supplier (e.g., Ambulance Company) that will bill Medicare Administrative Contractors for Part B medical services furnished to Medicare beneficiaries.
• CMS 855I -- Individual Health Care Practitioners - A physician or non-physician practitioner who renders medical services to Medicare beneficiaries must complete this application. This form is processed through the Medicare carrier.
• CMS 855R -- Individual Reassignment of Benefits - An individual who renders services and seeks to reassign his/her benefits to an eligible entity must complete this form for each entity eligible to receive reassigned benefits. The person must be enrolled in the Medicare program as an individual prior to reassigning his/her benefits. This form may be submitted concurrently with the Form CMS 855.
• CMS 855C – Indirect Payment Procedure (IPP) entities. These type of applications must be approved by the PEOG BFL.
• CMS 855O – Individual who is enrolling for the sole purpose of ordering and referring services to Medicare beneficiaries.
• CMS 855S -- DMEPOS Supplier Application - A supplier that whishes to enroll in the Medicare program and provide Medicare beneficiaries with durable medical equipment, prosthetics, orthotics, or supplies. The National Supplier Clearinghouse (NSC) is responsible for processing the application.
• FID -- Fraud Investigative Database
• Final adverse action -- one or more of the following actions:(i) A Medicare-imposed revocation of any Medicare billing privileges; (ii) Suspension or revocation of a license to provide health care by any State licensing authority; (iii) Revocation or suspension by an accreditation organization; (iv) A conviction of a Federal or State felony offense (as defined in section 424.535(a)(3)(i)) within the last 10 years preceding enrollment, revalidation, or re-enrollment; or (v) An exclusion or debarment from participation in a Federal or State health care program.
• Financial control -- (a) An organization or individual is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by the provider or any of the property or assets of the provider, and (b) The interest is equal to or exceeds five percent of the total property and assets of the provider.
• HCCL -- Health Care Clinic License (same as HCCR)
• HCCR license (health care services clinic) -- a business operating in a single structure or facility, or in a group of adjacent structures or facilities operating under the same business name or management, at which tender changes for reimbursement for such services. Section 456.0375, Florida Statutes, requires every such clinic to register separately even though operated under the same business name or management.
• Inactivate -- The provider/supplier will be unable to use its billing number for claims processing. Upon taking this action, notify the applicant you have done so and the reason.
• IRS Form 941 -- Employer’s Quarterly Federal Tax Return. This form can be used as IRS documentation showing the Tax ID and Legal Business Name of the entity. This form can only be accepted if it is pre-printed from the IRS with the Tax ID number and Legal Business Name.
• Joint venture -- A business undertaking involving a one-time grouping of two or more entities. Although a joint venture is treated like a partnership for Federal Income tax purpose, it is different form the latter as it does not involve a continuing relationship among the parties. Joint ventures are, in a sense, short-term partnerships. In a joint venture where there is no transfer of legal title of assets, no change of ownership (CHOW) occurs.
• Legal Business Name -- The name of a business that is reported to the IRS.
• Managing employee -- A managing employee is defined as a general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or through some other arrangement, whether or not the individual is a W-2 employee of the provider or supplier.
• Managing organization -- A managing organization is one that exercises operational or managerial control over the provider, or conducts the day-to-day operations of the provider. The organization need not have an ownership interest in the provider in order to qualify as a managing organization. For instance, the organization could be a management services organization under contract with the provider to furnish management services for one of the provider's practice locations.
• Medicare identification number -- The generic term for any number, other than the National Provider Identifier, used by a provider or supplier to bill the Medicare program. Some examples of Medicare identification numbers include:
• Unique Physician Identification Number (UPINs)
• Provider Identification Numbers (PINs)
• Online Survey Certification and Reporting (OSCAR)
• National Supplier Clearinghouse (NSC)
• Mobile facility/portable unit -- These terms apply when a service that requires medical equipment is provided in a vehicle or the equipment for the service is transported to multiple locations within a geographic area. The most common types of mobile facilities/portable units are:
• Mobile independent diagnostic testing facilities
• Portable X-ray units
• Portable mammography units
• Mobile clinics
Note: Physical therapists and other medical practitioners (e.g., physicians, nurse practitioners, physician assistants) who perform services at multiple locations (e.g., house calls, assisted living facilities) are not considered to be mobile facilities/portable units.
• National Provider Identifier -- The standard unique health identifier for health care providers (including Medicare suppliers) and is assigned by the National Plan and Provider Enumeration System (NPPES).
• Non-participating provider -- A provider who does not wish to sign the participation agreement.
• Operational -- The provider or supplier has a qualified physical practice location, is open to the public for the purpose of providing health care related services, is prepared to submit valid Medicare claims; and is properly staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered) to furnish these items or services.
• Opt out provider -- A provider that has been approved to withdraw (opt out) from the Medicare Program.
• Ordering physician or ordering non-physician practitioner – CMS-covered physician or non-physician practitioner who may order medical services for Medicare beneficiaries. The DVA, DOD or PHS must employ the individual. The DVA, DOD or PHS must have an active enrollment record in PECOS. The physician or non-physician practitioner will not be reimbursed for services rendered.
• Owner (Ownership) -- Any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of, the provider or supplier as defined in sections 1124 and 1124(A) of the Social Security Act.
• Ownership or control interest -- Section 1124(a)(3) of the Social Security Act, defines an individual with an ownership or control interest as: (1) A five percent direct or indirect owner of the provider, (2) An officer or director of the provider, if the provider is a corporation, or (3) A partner of the provider, if the provider is a partnership.
• Participating provider -- Must sign the participation agreement in order to be participating.
• PECOS – Provider Enrollment Chain and Organization System. A system that is used by CMS for physician/non-physician practitioners and organizations that have been approved. This system is used to store and update provider/supplier information.
• Physician or non-physician practitioner- CMS covered physician or non-physician practitioner who may refer Medicare beneficiaries to other providers or suppliers. The DVA, DOD or PHS must employ the individual. The DVA, DOD or PHS must have an active enrollment record in PECOS. The physician or non-physician practitioner will not be reimbursed for services rendered.
• Physician or non-physician practitioner organization -- Any physician or non-physician practitioner entity that enrolls in the Medicare program as a sole proprietorship or organization entity.
• Provider -- As defined at 42 CFR 400.202 and generally means a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility (CORF), home health agency or hospice, that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services; or community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services.
• Provider Access Transaction Number (PTAN) -- Providers/suppliers will be issued a PTAN to access their IVR data and may also be used to identify their NPI number on the NPI crosswalk. The PTAN is what was previously referred to as the Medicare Identification Number, Legacy Number and/or OSCAR number.
• Prospective provider -- means any entity specified in the definitions of “provider” in 42 CFR 498.2 that seek to be approved for coverage of its services by Medicare.
• Prospective supplier -- means any entity specified in the definition of “supplier” in 42 CFR 405.802 that seek to be approved for coverage of its services under Medicare.
• Reassignment -- An individual physician or non-physician practitioner, except physician assistants, has granted a clinic or group practice the right to receive payment for the practitioner’s services.
• Reject/Rejected -- The provider or supplier’s enrollment application was not processed due to incomplete information or that additional information or corrected information was not received from the provider or supplier in a timely manner.
• Revoke/Revocation -- The provider or supplier’s billing privileges are terminated.
• Specialty Care Transport (SCT) -- Inter-facility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle including medically necessary suppliers and services at a level of service beyond the scope of the EMT-Paramedic, SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area.
• Sole-owner -- A business structure in which an individual and his/her company are considered separate entities for tax and liability purposes. A sole ownership is a company that is registered with the state as a limited liability company, corporation, professional association, etc. The owner pays income tax separately for the company.
• Sole proprietor -- A business structure in which an individual and his/her company are considered a single entity for tax and liability purposes. A sole proprietorship is a company, which is not registered with the state as a limited liability company, corporation, etc. The owner is personally liable for all of the business debts and reports any business profits or losses on their individual tax return.
• Personal Supervision -- a physician must be in attendance in the room during the performance of the procedure.
• Direct Supervision -- the physician must be present in the office suite and immediately available to provide assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
• General Supervision -- the procedure is provided under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. General supervision also includes the responsibility that the non-physician personnel who perform the tests are qualified and properly trained and that the equipment is operated properly, maintained, calibrated and that necessary supplies are available.
• Supplier is defined in 42 CFR 400.202 and means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.
• Tax Identification Number -- The number (either the Social Security Number (SSN) or Employer Identification Number (EIN)) the individual or organization uses to report tax information to the IRS.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.