Glossary
Glossary
  • Abstract
  • Accounts Receivable
  • ACS
  • Adjudicated
  • Adjustment
  • ALTSD
  • Audit Number
  • AVRS
  • Billing Provider
  • Capitation
  • Claim
  • Client
  • CMS
  • CMS-1500
  • COE
  • Co-Payment
  • CPT
  • Crossover
  • CYFD
  • D&E
  • DD
  • Deductible
  • Denied Claims
  • DHHS
  • DME
  • DOB
  • DOH
  • DOS
  • DRG
  • Dual-Eligibles
  • Edit
  • Electronic Claims Submission
  • Eligibility Add-Date
  • EMC
  • Encounter
  • EOB
  • EOMB
  • EPSDT
  • Exception
  • Exempt
  • FFS (Fee-for-Service)
  • Financial Transactions
  • Fiscal Agent
  • FQHC
  • Full Benefits
  • HCBS Waiver
  • HCFA
  • HCFA 1500
  • HCPCS
  • HIPAA
  • HMO
  • HSD
  • ICD-9
  • ICF-MR
  • IHS
  • ISD
  • Julian Date
  • Limited Benefits
  • Local Codes
  • Lock-in
  • LTC (Long-Term Care)
  • MAD
  • MCC
  • MCO
  • Medicaid
  • Medicare
  • Medicare Part A
  • Medicare Part B
  • Medicare Part C
  • Medicare Part D
  • MEVS
  • MMIS
  • Molina TPA
  • NMMUR
  • NMRx
  • Noncovered Services
  • Nonexempt
  • NPI
  • OCR
  • OMB
  • Omnicaid
  • Optum Health
  • OT
  • PA
  • PACE
  • Paid Claims
  • Payerpath
  • PCO (Personal Care Option)
  • PDL (Preferred Drug List)
  • PE/MOSAA
  • Pend
  • Place of Service
  • Point of Sale
  • POS
  • PPO
  • Presumptive Eligibility
  • Prior Authorization
  • Proof of timely filing
  • Provider
  • QMB
  • RA
  • Real-Time Inquiry/Processing
  • Recoupment
  • Remittance Advice
  • Rendering Provider
  • Retroactive Eligibility
  • RHC
  • RTP
  • SALUD!
  • SCHIP
  • SCI
  • Servicing Provider
  • SSA
  • SSI
  • TAD
  • Taxonomy
  • TCN
  • TIE
  • TPL (Third Party Liability)
  • Translator
  • UB-04
  • UR (Utilization Review)
  • Void
  • Waiver
  • Warrant

  • Note: If you cannot find a Medicaid related term here, check out one of the following helpful links:

    Centers for Medicaid & Medicare Services Glossary

    Medical Assistance Division Glossary

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    Abstract

    The term commonly used to identify the paperwork submitted to utilization review to determine if a patient meets the medical criteria to be in a nursing home or ICF-MR. Abstract is also used to describe the long term care authorization span that resides on Omnicaid.

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    Accounts Receivable

    Also referred to as Account Receivables on the RA. Refers to monies owed by the provider to NM Medicaid. For more information see recoupment.

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    ACS

    ACS' a Xerox Company New Mexico Medicaid Project provides fiscal agent operations services for the state of New Mexico's Fee For Service Medicaid program. ACS contracts with the New Mexico Medical Assistance Division to process fee-for-service claims. Some of ACS' responsibilities include the following operations: enroll providers, process and pay claims, respond to provider inquiries and maintain the NM Medicaid Web Portal.

    ACS processes and pays claims based on MAD policy. ACS does not make Medicaid policy and cannot make changes to policy. Click here for ACS contact information.

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    Adjudicated

    Refers to a claim about which Omnicaid has made a decision - this includes pend status claims as well as paid and denied claims.

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    Adjustment

    An adjustment form is used to make changes to a previously paid claim usually with the expectation that the payment will increase or decrease. Sometimes, however, adjustments are submitted to correct billing errors, particularly in the number of units billed on the original claim.

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    ALTSD

    Aging and Long Term Services Department. Administers the Disabled and Elderly Waiver program and PCO.

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    Audit Number

    Eligibility inquiry systems (AVRS, MEVS, and Online Eligibility Inquiry) provide you with an 'audit' number that can be used to trace back to the inquiry record should there be a discrepancy. However, no audit number is issued for calls to our Eligibility Help Desk.

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    AVRS

    Automated Voice Response System. A quick way to check eligibility for up to ten clients. Be sure to make note of the audit number provided to you. AVRS can be reached at 800-820-6901. See also MEVS.

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    Billing Provider

    A provider or organization that can bill for a claim. Upon enrollment with NM Medicaid, providers are classified as billing providers or rendering/servicing providers. Note that some providers are billing and servicing providers.

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    Capitation

    Payment that NM Medicaid makes to managed care organizations, such as the SALUD! plans on behalf of Medicaid clients.

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    Claim

    A provider's request for payment for services rendered to a Medicaid client.

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    Client

    Medicaid recipient. Client and recipient are often used interchangeably.

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    CMS

    Meaning varies based on context:

    1. Centers for Medicare and Medicaid Services (Federal Government Organization)
      1. CMS Homepage
      2. A division of the Department of Health & Human Services
      3. The federal agency that deals with legislative and public affairs pertaining to Medicare and Medicaid.
      4. Formerly known as the Health Care Financing Administration.
    2. Children's Medical Services (NM DOH)
      1. Provides services and support, medical care, and referrals for children with chronic conditions and preventative care for children with chronic illnesses and children who qualify for the Healthier Kids Fund.
      2. State CMS office: (505) 476-8868 / DOH Website
      3. Click here for more information about the Children's Medical Services client eligibility.
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    CMS 1500

    Claims submission form for professional providers. Formerly referred to as the HCFA 1500.

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    COE

    Category of eligibility. The COE is assigned to clients based on the program under which they have been qualified for Medicaid eligibility. The COE can determine the level of Medicaid benefits for which the client is eligible.

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    Co-Payment

    Refers to the client's share of the payment to a provider.

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    CPT

    Current Procedural Terminology. Also known as HCPCS Level I. Codes that professional providers use to bill medical services. Click here to go to the AMA's Downloadable CPT materials.

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    Crossover

    Crossover is the term commonly used to describe a claim for a Medicare/Medicaid dual eligible client that is processed by Medicaid as the secondary payer. The term comes from the fact that a claim for a dual eligible client is submitted to Medicare first and then Medicare 'crosses over the claim,' that is, Medicare sends the paid claim electronically to Medicaid for secondary processing. A crossover claim, therefore, is a claim where Medicare is primary and has paid some or all of the claim, and where Medicaid is secondary and pays any remainder owed by Medicaid. For more information, click here for Medicare FAQs.

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    CYFD

    Children Youth & Families Department.

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    D&E

    Disabled and Elderly Waiver - This is an HCBS waiver program designed for elderly persons who qualify for Medicaid nursing home services to be cared for in their home, rather than going to an institution for care.

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    DD

    Developmental Disabilities Waiver - This is an HCBS waiver program designed for developmentally disabled persons who qualify for Medicaid ICF-MR services to be cared for in their home, rather than going to an institution for care.

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    Deductible

    Amount that a client with TPL or Medicare must pay before full health benefits coverage begins. For Medicaid clients with TPL or Medicare, Medicaid (generally) pays the deductible.

     

    Click here for Medicare FAQs.

    Click here for TPL FAQs.

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    Denied Claims

    Refers to adjudicated claims that Medicaid did not pay. Medicaid claims can deny for a number of reasons. Click here to go to EOB Troubleshooting for more information on why a claim denied and if it can be paid.

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    DHHS

    Department of Health and Human Services. CMS is one of many DHHS agencies. For more information about DHHS, click here.

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    DME

    Durable Medical Equipment. Medical equipment that can be used repeatedly (such as a wheelchair) as opposed to medical supplies, which are generally exhausted within one to a few uses.

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    DOB

    Date of birth. The DOB is used to verify Medicaid client eligibility. Typically refers to the Medicaid client's date of birth and not that of a parent or guardian. The DOB is required on claims; reference EOB Troubleshooting for the Name/DOB mismatch claim denial reason code.

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    DOH

    Department of Health. A department of New Mexico state government focused on health policy, public health issues and disease prevention. The DOH funds the Children's Medical Services (CMS) program. The DOH is also responsible for administration the Home and Community Based (HCBS) Waiver program, except for the Disabled and Elderly program, which is administered by the Aging and Long Term Services Department (ALTSD).

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    DOS

    Date(s) of service. Refers to the time period during which the client was treated.

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    DRG

    Diagnosis Related Group. A prospective payment structure for acute-care hospitals. Reimbursement is per discharge at a fixed amount based on the estimated resource usage, length of stay, client's age, and medical diagnosis.

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    Dual-Eligibles

    Clients who are eligible for both Medicare and Medicaid. Refers specifically to clients who receive full Medicaid benefits as opposed to QMB Medicaid clients whose only Medicaid benefit is the payment of crossover claims after Medicare pays as primary.

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    Edit

    Edit and exception are used interchangeably in terms of claims processing. The Omnicaid system edits claims (for policy issues, billing errors, etc.) and if the system denies the claim or pays at a different amount than on the original claim, an exception code is listed on the RA / EOB. This code explains why a claim or line item processed a certain way.

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    Electronic Claims Submission

    Submission of Medicaid claims electronically. Also referred to as EMC.

    The most efficient means of claims submission because it is faster and results in fewer errors than paper claims submission. See Payerpath for more information.

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    Eligibility Add Date

    The date on which a client's Medicaid eligibility was added to Omnicaid. This date is essential for determining if a claim falls under retroactive eligibility timely filing guidelines.

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    EMC


    Electronic Media Capture. Another term for electronic claims submission.

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    Encounter

    An encounter is a face-to-face service between a patient and a medical professional. FQHCs, RHCs and IHS bill their outpatient services as an 'encounter.'

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    EOB

    Explanation of Benefits. Also known as the Remittance Advice (RA). Can refer to the EOB codes that appear on our online claims inquiry and the Remittance Advice itself. EOB codes can provide an explanation of why claims denied or paid a certain way.

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    EOMB

    Explanation of Medicare Benefits. If the claim was submitted to Medicare, but did not crossover electronically to Medicaid, attach this document to your Medicaid claim in order for Medicaid to make a payment decision.

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    EPSDT

    Early Periodic Screening, Diagnosis, and Treatment. For more information about EPSDT billing, click here to go to the EPSDT FAQ.

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    Exception

    Edit and exception are used interchangeably in terms of claims processing. The Omnicaid system edits claims (for policy issues, billing errors, etc.) and if the system denies the claim or pays at a different amount than on the original claim, an exception code is listed on the RA / EOB. This code explains why a claim or line item processed a certain way.

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    Exempt

    A term frequently used by Medicaid providers to describe a client who is not enrolled in SALUD!. NM Medicaid FFS pays for an exempt client's claims.

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    FFS (Fee-for-Service)

    The following claims are considered fee-for-service: Claims for clients not enrolled in SALUD!; claims for physical health services not covered by the SALUD! program; or for behavioral health crossover claims. Fee for service claims are the only Medicaid claims paid by ACS. Fee-for-service is another term that can be used to describe a client who is exempt, or not enrolled in SALUD!.

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    Financial Transactions

    Non-claim related transactions that set up and/or satisfy an account receivable or create a pay-out. See recoupment, void, or adjustment for more information.

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    Fiscal Agent

    See ACS.

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    Full Benefits

    Refers to clients who are eligible for all services that are covered by NM Medicaid. Refer to your Policy Manual and Billing Instructions for further information.

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    FQHC

    Federally Qualified Health Center. Primary health care clinics that provide different kinds of healthcare services such as physical health services, behavioral health services and dental services. These facilities have a special status with Medicare and Medicaid and must meet certain requirements set by Medicare to qualify as an FQHC. Their Medicaid and Medicare reimbursement methodology differs from reimbursements made to a conventional doctor's office. FQHCs were developed especially to serve rural communities and underserved populations.

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    HCBS Waiver

    Home and Community Based Services Waiver. See Waiver for more information.

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    HCFA

    Health Care Financing Administration. Federal government organization now called CMS (Centers for Medicare and Medicaid)

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    HCFA 1500

    Claims submission form for professional providers. Now referred to as the CMS 1500.

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    HCPCS

    Healthcare Common Procedural Coding System. HIPAA-compliant code set.

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    HIPAA

    Health Insurance Portability and Accountability Act. Click here to go to the Department of Health & Human Services HIPAA website.

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    HMO

    Health Maintenance Organization - the health plan for a traditional managed care insurance. Consumers must see providers within the HMO networks and only owe copayments for services received.

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    HSD

    Human Services Department. MAD and ISD are part of HSD.

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    ICD-9

    International Classification of Diseases, 9th Edition. Used to classify and enumerate surgical procedures and diagnoses.

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    ICF-MR

    Intermediate Care Facility for the Mentally Retarded.

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    IHS

    Indian Health Service. Health care delivery system for Native Americans.

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    ISD

    Income Support Division. Part of the New Mexico Human Services Department (HSD), ISD makes Medicaid eligibility decisions for most Medicaid clients.

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    Julian Date

    Represents the date through a numeric count of all days in the year (as opposed to Month/Date format). For example, the Julian Date for January 1 is 001. The Julian Date for December 31 in a non-leap year is 365.The Julian Date is used in the TCN.

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    Limited Benefits

    Certain COEs have limited Medicaid Benefits, which means that clients with these COEs are not eligible for all services covered by NM Medicaid. Some examples include QMBs and women with family planning only coverage.

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    Local Codes

    Formerly referred to as HCPCS Level III codes used before HIPAA standard codes went into effect.

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    Lock-in

    Time-period in which a Medicaid client is enrolled in a Managed Care Organization. Click here for Frequently Asked Questions about MCOs.

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    LTC (Long-Term Care)

    Healthcare for clients of any age with disabilities or chronic conditions. Used to refer to services furnished in nursing homes and ICF-MRs.

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    MAD

    Medical Assistance Division. Part of the New Mexico Human Services Department (HSD), MAD is New Mexico's Medicaid agency; MAD administers the New Mexico Medicaid program. Click here for MAD contact information. ACS is the fiscal agent for MAD.

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    MCC

    Medical Care Credit. An amount of money that a nursing home resident or resident of an ICF-MR owes towards his or her care. Also called patient liability.

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    MCO

    Managed Care Organization. Most NM Medicaid clients are enrolled in a Managed Care Organization. SALUD! is the name of the managed care program for physical health care. The Statewide Entity for behavioral health services is Optum Health. All clients not enrolled in SALUD! are enrolled in NMRx for pharmacy benefits, with the exception of nursing home residents. When inquiring about client eligibility, make note of changes in plan enrollment. It is not uncommon for a SALUD! client to be enrolled in a SALUD! MCO one month and to be disenrolled from SALUD! the following month, which means claims for dates of service in that month are paid by Fee-for-Service. This is why it is so important to check client eligibility every time you see a patient.

    Contact Information for the SALUD! Managed Care Organizations in New Mexico:

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    Molina: 1-877-373-8986

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    Presbyterian: 888-977-2333

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    Lovelace: 888-232-2750

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    Blue Salud!: 866-689-1523

    Click here for MCO FAQs.

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    Medicaid

    A joint state and federal program, which pays for health care services on behalf of low- income individuals who meet specific criteria. When used on this site, refers specifically to New Mexico's Medicaid program and to Fee-for-service Medicaid (unless otherwise noted).

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    Medicare

    A federal health insurance program that provides benefits to those age 65 and older, to those who have received Social Security disability benefits for 24 consecutive months, and to those who have end-stage renal disease. The Social Security Administration Office (SSA) determines Medicare eligibility.

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    Medicare Part A

    Medicare institutional healthcare insurance that pays for the following services: inpatient and outpatient hospital, nursing home, home health, FQHC, RHC, and hospice.

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    Medicare Part B

    Medicare medical healthcare insurance that pays for doctors' services, ambulance services, durable medical equipment and certain other 'professional' services.

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    Medicare Part C

    Medicare Advantage, often referred to as a Medicare Replacement Plan or a Senior Plan. Medicare recipients can choose to enroll in a managed care plan instead of traditional Medicare coverage (fee-for-service). Click here for more information about billing for clients with Medicare Part C.

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    Medicare Part D

    Prescription drug coverage for Medicare recipients. For dual-eligibles, Medicare Part D covers the majority of clients' prescriptions and they are also enrolled in NMRx or fee-for-service Medicaid for pharmacy items that are not covered by Medicare D. Medicaid does not cover the copays owed for Medicare D covered drugs. Medicaid does not pay for drugs covered by Medicare D but not covered in the drug plan in which the client is enrolled.

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    MEVS

    Medicaid Eligibility Verification System. A MEVS service is a client eligibility inquiry service offered by various vendors. These services have a fee associated with them and usually allow the user to submit eligibility inquiries to numerous health plans such as Medicare, Medicaid, and commercial health plans. MEVS eligibility inquiries are one-at-a-time, real-time inquiries. Some MEVS services allow for 'batch' inquiries, which allow users to submit a list of clients. Batch inquiries usually process over night with results delivered the following day.

    Follow the link below for:

    MEVS vendors for New Mexico Medicaid eligibility inquiries:

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    MMIS

    Medicaid Management Information System. Omnicaid is the name of New Mexico's MMIS.

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    Molina Healthcare TPA

    Molina Healthcare is the current NM Medicaid Utilization Review third party assessor (TPA). Molina Healthcare TPA is responsible for conducting Utilization Review (UR) for Medicaid Fee-For-Service (FFS) programs, Emergency Medical Services for undocumented Aliens (EMSA), and assessment functions for certain home health, long-term care, and Home and Community-Based Waiver services including Nursing Facilities, the Personal Care Option (PCO) and Mi Via programs. Molina Healthcare TPA can be contacted directly at 1-866-916-3250 or 505-348-0311.

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    NMRx

    The name of the PDL pharmacy program administered by Presbyterian Health Plan. Click here to find pharmacies participating in NMRx.

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    NMMUR

    New Mexico Medicaid Utilization Review. This is the term used for NM Medicaid's UR review Third party assessor (TPA), Molina. See UR for more information. Click here to go to Molina TPA's web site.

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    Noncovered Services

    Services not covered by NM Medicaid.

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    Non-exempt

    A term frequently used by Medicaid providers to describe a Medicaid client who is enrolled in SALUD!

    Note: This is not an 'official' NM Medicaid term, but was adopted by providers after the SALUD! program was implemented.

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    NPI

    National Provider Identifier. A unique, 10-digit, all numeric provider number issued by the federal government to all health care providers. As of May 23, 2007, the NPI is the only provider ID that can be used to identify the provider on all HIPAA compliant electronic transactions.

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    OCR

    Optical Character Recognition. A device that electronically reads paper claims, reduces data entry errors, and speeds up claims processing. Click here for more information on OCR, including Do's and Don'ts for paper claim submission.

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    OMB

    Office of Management and Budget. A federal office at the executive level that approves a number of payment rates for IHS facilities.

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    Omnicaid / MMIS

    Omnicaid is the name of New Mexico's Medicaid Management Information System (MMIS). Omnicaid maintains provider and client eligibility information; processes and adjudicates claims; and issues RAs and payments.

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    Optum Health

    Optum Health is the 'Statewide Entity' (SE) for managing New Mexico's public mental health and substance abuse services provided and/or funded by 15 separate state agencies in partnership with the New Mexico Behavioral Health Collaborative. Click here for more information about the Behavioral Health Collaborative and Optum Health.

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    OT

    Occupational Therapy

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    PA

    Prior Authorization. Some services require prior approval for medical necessity before Medicaid will pay for them. The following is a list of entities that issue prior authorization:

    • CYFD - for certain services for clients who qualify for Medicaid through CYFD.
    • CMS - for clients served by the Children's Medical Services program of the DOH.
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    PACE

    Program of All-inclusive Care for the Elderly. Helps the elderly remain in their home longer by providing medical and social services.

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    Paid Claims

    Refers to adjudicated claims that Medicaid paid. The amount Medicaid pays depends upon the billed amount, the Medicaid allowed amount, and the responsibility of another payer (such as Medicare or TPL).

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    Payerpath

    Web-based electronic claims submission tool. Offered by the State of New Mexico at no charge to NM Medicaid providers. Click here for information about electronic claims submission.

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    PCO

    Personal Care Option. The personal care option is for clients who wish to stay at home, but require the level of care that is normally provided in a nursing home. For more information about the PCO program, click here to go to the NM Aging and Long Term Services Department's PCO website.

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    PDL

    Preferred Drug List. Also called a formulary. A list of drugs that are covered by the plan. Providers must obtain prior authorization for drugs that are not on the client's NMRx PDL.

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    PE/MOSAA

    Presumptive Eligibility/Medicaid On-Site Application Assistance

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    Pend

    A claim that is neither paid nor denied. Some pended (or suspended) claims require review by an ACS claims reviewer. Other claims are pended for a certain length of time to allow eligibility information to be sent to ACS and put into Omnicaid. The most common reason for a claim to be in a pend or suspended status is client eligibility.

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    Place of Service

    A two-digit code that identifies where the service was performed.

    Transportation providers click here.

    Waiver providers click here.

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    Point of Sale

    Pharmacy claims submission system. A POS system sends claims directly to the client's insurer in real-time. Also called Point of Service.

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    POS

    See Point of Sale (Pharmacy) and Place of Service.

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    PPO

    Preferred Provider Organization - a modified managed care health plan where coverage is better when the consumer uses one of the plan's preferred providers but, for the most part, coverage exists when out-of-network providers are accessed. Copayments, deductibles and coinsurance can all be consumer responsibilities.

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    Presumptive Eligibility

    Presumptive eligibility is a COE that provides Medicaid benefits for up to 60 days to individuals who will likely meet Medicaid income guidelines. Specially-trained staff at doctor's offices, clinics and schools determine presumptive eligibility. The eligibility is intended to provide benefits for pregnant women and children while they apply for longer term Medicaid benefits through ISD. Presumptive eligibility is available to pregnant women and to children who may qualify for SCHIP. Presumptive eligibility for pregnant women covers prenatal care only.

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    Prior Authorization

    See PA.

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    Proof of timely filing

    Written documentation or correspondence from ACS which indicates that a claim was submitted within the original filing limit. This is usually an RA showing the original claim denial or payment. Proof of timely filing can also be 'Return to Provider' (RTP) forms that ACS has used to return an unprocessed claim to the provider. An RA for a claim that originally denied for exceeding the filing limit is not adequate proof of timely filing. ACS cannot accept billing notes or return receipts for certified mail as proof of timely filing. Click here to find out more about timely filing rules.

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    Provider

    An individual, business, clinic, facility or professional group that provides healthcare services or products to individuals.

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    QMB

    Qualified Medicare Beneficiary. A COE with limited Medicaid benefits. Medicaid only covers crossovers for QMB clients. This means that Medicare must approve the service before Medicaid can pay any deductible and/or coinsurance. If Medicare denies a service, Medicaid will not pay for it. See QMB FAQ for more information.

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    RA

    Remittance advice. The Remittance Advice (RA) is also known as an Explanation of Benefits (EOB), and is available on the NM Medicaid Portal. The RA lists claims that a provider has submitted and ACS has processed, explaining which claims are pended, paid or denied (and the reason for denial). A financial summary is also included in the RA.

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    Real Time Inquiry/Processing

    Real time is a 'technology' term. For inquiries, 'real time' means the information being read and retrieved is what is currently on file at that moment on the source system. For claims processing, 'real time' means the claim is processed using all the data that are currently on file at the moment the claim is processing. On-line claim status, client eligibility and prior authorization inquiries with ACS are all in 'real time' because they use the information that is on Omnicaid at the moment the inquiry is made.

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    Recoupment

    Recovery of overpayments to providers. MAD can direct ACS to recoup payment for a number of reasons including TPL payments, inadvertent overpayments, and license termination. Recoupments by MAD can be made without prior notice to the provider. Providers can submit adjustment requests that result in a lower payment than was originally made. The difference between the two payments becomes a recoupment. Providers can submit void requests where the entire original payment is returned to MAD. A void results in a recoupment. If a recoupment amount is created on an RA where payments for other claims are owed to the provider, the recoupment amount is recovered against the payment that Medicaid owes. If the recoupment amount is not fully recovered, the balance of the monies owed is forwarded to the next RA and applied to the next payment that Medicaid owes the provider. Click here for more information about Financial Transactions on the RA.

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    Remittance Advice

    See RA.

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    Rendering Provider

    The healthcare provider who performed the service(s) listed on the claim. The rendering provider's Medicaid ID should be entered in the unshaded area of Box 24J on the CMS-1500 claim form. The rendering provider's ID should not be entered as the billing provider unless the provider is enrolled with Medicaid as an 'unrestricted' provider who can be both a billing and a rendering provider. Also called 'servicing' provider.

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    Retroactive Eligibility

    Refers to a client whose Medicaid eligibility is made effective at a time in the past. This is very common for clients who qualify for SSI, when the eligibility can be made effective years in the past. Most other Medicaid clients do not get retroactive Medicaid benefits awarded as far back as SSI. Medicaid clients who qualify for retroactive Medicaid benefits are required to immediately notify providers of their Medicaid eligibility. Click here for more information on retroactive eligibility and claims processing.

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    RHC

    Rural Health Center. RHCs are health clinics located in areas that are both rural (as defined by the census) and medically under-served (defined by the Secretary of the Department of Health and Human Services: DHHS). These clinics can be 'free-standing' or 'hospital-based' and are considered institutional billers.

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    RTP

    Return to Provider. A form that ACS attaches to claims when mailed back to a provider. Reasons claims are sent back include errors in claim data, attachments, and crossover data.

    Due to changes in claims processing technology, ACS adjudicates more claims with missing information and sends fewer claims back to providers. This reduces the risk of losing claims in the mail and speeds up claims processing by using the RA to alert providers to claim errors.

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    SALUD!

    SALUD! is the name of NM Medicaid's managed care program for physical health services. The SALUD! program was introduced in July 1997. See MCO for more information.

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    SCHIP

    State Children's Health Insurance Program. SCHIP provides Medicaid to children under 19 whose family income is between 185-235% of the Federal Income Poverty Guidelines. New Mexico administers SCHIP through the Medicaid program. NM SCHIP extends Medicaid benefits to low income children who would not otherwise be eligible for Medicaid. For SCHIP co-payment amounts, click here.

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    SCI

    State Coverage Insurance. SCI is a program operated by the Medical Assistance Division that allows working individuals to buy affordable health insurance through their employers. This program is also offered to self-employed individuals. Persons who have been found eligible for SCI through the ISD are assigned a COE, but this COE does not entitle them to regular Medicaid benefits.

    Click here to go to the State Coverage Insurance Website

    Click here for more information about SCI and Medicaid Billing

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    Servicing Provider

    See Rendering Provider.

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    SSA

    Social Security Administration. SSA makes eligibility determinations for SSI. Clients who receive SSI automatically qualify for Medicaid.

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    SSI

    Supplemental Security Income. A monthly cash assistance program for disabled individuals. Clients who receive SSI automatically qualify for Medicaid.

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    TAD

    Turnaround Document. This term is used to describe the Reverification Turnaround Document which is sent to all providers every 2 years. The purpose of the TAD is to have providers verify and update the information on their provider file with ACS.

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    Taxonomy

    A 10-digit, alpha-numeric code that represents a health care provider's type and specialty. It can accompany the NPI to provide more information about the provider in HIPAA electronic transactions.

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    TCN

    Transaction Control Number. An ACS-assigned, unique 17-digit number that is associated with a single, processed claim. This number is the unique identifier for a processed claim. A claim cannot be assigned a TCN that has already been assigned to a different claim. Each claim's TCN is listed in the RA. Click here for more information about the meaning behind the digits of a TCN.

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    TIE

    Transaction Interface Exchange. The State of New Mexico's translator for HIPAA standard transactions.

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    TPL

    Third Party Liability, also referred to as 'commercial' or 'private' insurance. If a Medicaid client has TPL, that company is the primary insurer. Click here for more information on TPL.

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    Translator

    See TIE

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    UB-04

    Uniform Bill, 2004. The current version of the paper claim form used by institutional billers such as hospitals and long term care facilities. This form accomodates the NPI and taxonomy codes.

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    UR

    Utilization Review. UR is a term that is often used to refer to the entity that determines medical necessity and issues prior authorization for certain services. Molina TPA is the UR contractor to MAD for the fee-for-service program. The SALUD! MCOs have their own UR departments, as does Optum Health.

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    Void

    A void is used to completely 'negate' a paid claim. Voids result in recoupment of the payment. Void a claim when you billed the claim in error (example: client did not inform you that she had TPL coverage).

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    Waiver

    Also referred to as the HCBS (Home and Community Based Services) Waiver. A program that allows clients who qualify for Medicaid institutional services to obtain services in their home instead of in an institution. Click here for more information about the Waiver Categories of Eligibility.

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    Warrant

    The 'official' term for the payment check or electronic funds transfer (EFT) ) that providers of service receive. Medicaid warrants are paid from New Mexico's Human Services Division accounts. ACS neither distributes funds to providers from its own accounts; nor does ACS deposit provider funds into its own accounts.

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