Medical Billing Module 11: Part Two

Medicaid

adjusted claim

payment correction resulting in additional payment(s) to the provider.

Basic Health Program (BHP)

health benefits coverage program for residents with low incomes who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace; implemented by Affordable Care Act to give states the ability to provide more affordable coverage to residents with low incomes and improve continuity of care for people whose income fluctuates above and below Medicaid and CHIP income eligibility levels; states contract with one or more private insurance companies to provide coverage to eligible residents at affordable premiums.

Children’s Health Insurance Program (CHIP)

provides health insurance coverage to uninsured children whose family income is up to 200 percent of the federal poverty level (monthly income limits for a family of four also apply).

dual eligibles

individuals entitled to Medicare and eligible for some type of Medicaid benefit.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services

legislation that mandates states to provide routine pediatric checkups to all children enrolled in Medicaid.

Federal Medical Assistance Percentage (FMAP)

portion of the Medicaid program paid by the federal government.

federal poverty level (FPL)

income guidelines established annually by the federal government.

Medicaid

cost-sharing program between the federal and state governments to provide health care services to Americans with low incomes.

Medicaid eligibility verification system (MEVS)

sometimes called recipient eligibility verification system or REVS; allows providers to electronically access the state’s eligibility file through point-of-sale device, computer software, and automated voice response.

Medicaid remittance advice

sent to the provider; serves as an explanation of benefits from Medicaid and contains the current status of all claims (including adjusted and voided claims).

medical assistance programs

provides health care coverage to individuals with low incomes.

newborn claim

submitted for services provided to a newborn under the parent’s Medicaid identification number.

recipient eligibility verification system (REVS)

also called Medicaid eligibility verification system (MEVS); allows providers to electronically access the state’s eligibility file through point-of-sale device, computer software, and automated voice response.

surveillance and utilization review subsystem (SURS)

safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services.

voided claim

claim Medicaid should not have originally paid, resulting in a deduction from the lump-sum payment made to the provider.