Chiropractic Handbook
 
 

Glossary of Common Terms

Adjustment
A modified or changed claim that was originally allowed, at least in part, by Wisconsin Medicaid.

Allowed Claim
A Medicaid or Medicare claim that has at least one service that is reimbursable.

BadgerCare
BadgerCare extends Medicaid coverage through a Medicaid expansion under Titles XIX and XXI to uninsured children and parents with incomes at or below 185 percent of the federal poverty level and who meet other program requirements. The goal of BadgerCare is to fill the gap between Medicaid and private insurance without supplanting or "crowding out" private insurance.

BadgerCare benefits are identical to the benefits and services covered by Wisconsin Medicaid and recipients’ health care is administered through the same delivery system.

CMS
Centers for Medicare and Medicaid Services. An agency housed within the U.S. Department of Health and Human Services (DHHS), the CMS administers Medicare, Medicaid, related quality assurance programs, and other programs.

CPT
Current Procedural Terminology. A listing of descriptive terms and codes for reporting medical, surgical, therapeutic, and diagnostic procedures. These codes are developed, updated, and published annually by the American Medical Association and adopted for billing purposes by the Centers for Medicare and Medicaid Services (CMS) and Wisconsin Medicaid.

Crossover Claim
A Medicare-allowed claim for a dual entitlee submitted to Wisconsin Medicaid for possible additional payment of the Medicare coinsurance and deductible.

DHCF
Division of Health Care Financing. The DHCF administers Wisconsin Medicaid for the Department of Health and Family Services (DHFS) under statutory provisions, administrative rules, and the state’s Medicaid plan. The state’s Medicaid plan is a comprehensive description of the state’s Medicaid program that provides the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (DHHS) assurances that the program is administered in conformity with federal law and CMS policy.

DHFS
Department of Health and Family Services. The DHFS administers Wisconsin Medicaid. Its primary mission is to foster healthy, self-reliant individuals and families by promoting independence and community responsibility; strengthening families; encouraging healthy behaviors; protecting vulnerable children, adults, and families; preventing individual and social problems; and providing services of value to taxpayers.

DHHS
Department of Health and Human Services. The United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.

The DHHS includes more than 300 programs, covering a wide spectrum of activities, including overseeing Medicare and Medicaid; medical and social science research; preventing outbreak of infectious disease; assuring food and drug safety; and providing financial assistance for low-income families.

DOS
Date of service. The calendar date on which a specific medical service is performed.

Dual Entitlee
A recipient who is eligible for both Medicaid and Medicare, either Medicare Part A, Part B, or both.

EDI
Electronic Data Interchange. The DHCF EDI department processes electronic transactions for Wisconsin Medicaid. For more information regarding the EDI Department, contact the EDI Helpdesk at (608) 221-9036 or e-mail wiedi@dhfs.state.wi.us.

Emergency Services
Those services which are necessary to prevent death or serious impairment of the health of the individual.

EOB
Explanation of Benefits. Appears on the provider’s Remittance and Status (R/S) Report and notifies the Medicaid provider of the status or action taken on a claim.

EVS
Eligibility Verification System. Wisconsin Medicaid encourages all providers to verify eligibility before rendering services, both to determine eligibility for the current date and to discover any limitations to a recipient’s coverage. Providers may access recipient eligibility information through the following methods:

Fee-for-Service
The traditional health care payment system under which physicians and other providers receive a payment for each unit of service provided rather than a capitation payment for each recipient.

Fiscal Agent
The Medicaid fiscal agent (EDS) is under contract with the Department of Health and Family Services (DHFS) to certify providers, process and pay claims, answer provider and recipient questions, issue identification cards to recipients, publish information for providers and recipients, and maintain the Wisconsin Medicaid Web site.

HCPCS
Healthcare Common Procedure Coding System. A listing of services, procedures, and supplies offered by physicians and other providers. HCPCS includes Current Procedural Terminology (CPT) codes and national alphanumeric codes. The national codes are developed by the Centers for Medicare and Medicaid Services (CMS) to supplement CPT codes.

HealthCheck
A program which provides Medicaid-eligible children under age 21 with regular health screenings.

ICD-9-CM
International Classification of Diseases, Ninth Revision, Clinical Modification. Nomenclature for medical diagnoses required for billing. Available through the American Hospital Association.

Maximum Allowable Fee Schedule
A listing of all procedure codes allowed by Wisconsin Medicaid for a given provider type and the maximum allowable fee and relative value units (RVUs) Wisconsin Medicaid assigns to each procedure code. Providers may download service-specific fee schedules on the Medicaid Web site at dhs.wisconsin.gov/medicaid/.

Medicaid
Medicaid is a joint federal/state program established in 1965 under Title XIX of the Social Security Act to pay for medical services for people with disabilities, people 65 years and older, children and their caretakers, and pregnant women who meet the program’s financial requirements.

The purpose of Medicaid is to provide reimbursement for and assure the availability of appropriate medical care to persons who meet the criteria for Medicaid. Medicaid is also known as the Medical Assistance Program, Title XIX, or T19.

Medically Necessary
According to HFS 101.03(96m), Wis. Admin. Code, a service that is:

  1. Required to prevent, identify or treat a recipient’s illness, injury or disability; and
  2. Meets the following standards:
  1. Is consistent with the recipient’s symptoms or with prevention, diagnosis or treatment of the recipient’s illness, injury or disability;
  2. Is provided consistent with standards of acceptable quality of care applicable to type of service, the type of provider and the setting in which the service is provided;
  3. Is appropriate with regard to generally accepted standards of medical practice;
  4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient;
  5. Is of proven medical value or usefulness and, consistent with s. HFS 107.035, is not experimental in nature;
  6. Is not duplicative with respect to other services being provided to the recipient;
  7. Is not solely for the convenience of the recipient, the recipient’s family or a provider;
  8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and
  9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.

Payee
Party to whom checks are made payable. The payee’s address is used as the mailing address for checks and Remittance and Status (R/S) Reports.

POS
Place of service. A two-digit code which identifies the place where the service was performed.

QMB-Only
Qualified Medicare Beneficiary under the Medicare Catastrophic Health Act. These recipients are only eligible for the payment of the coinsurance and the deductible for Medicare-allowed claims.

Qualifying Circumstances
Conditions that complicate the rendering of anesthesia services, including the extraordinary condition of the patient, special operative conditions, and unusual risk factors.

R/S Report
Remittance and Status Report. A statement generated by Wisconsin Medicaid to inform the provider regarding the processing of the provider’s claims.

Spell of Illness
Per HFS 107.15, Wis. Admin. Code, a spell of illness is defined as one of the following:

Chiropractic Services Handbook
PHC 1306, October 2004