It can be used to order a financial institution to make a by 6dLM8xu


									                                                        Revised – 20110929

               Glossary of Terms
270   The HIPAA compliant transaction used to inquire about the
      health care benefits and eligibility associated with a
      subscriber or dependent

271   The HIPAA compliant transaction used to respond to a
      request inquires about the health care benefits and eligibility
      associated with a subscriber or dependent

276   The HIPAA compliant transaction used by a provider, recipient
      of health care products or services or their authorized agent
      to request the status of a health care claim

277   The HIPAA compliant transaction used by a health care payer
      or authorized agent to notify a provider, recipient or
      authorized agent regarding the status of a health care claim
      or encounter, or to request additional information from the
      provider regarding a health care claim or encounter

278   The HIPAA compliant transaction used to transmit health care
      service information, such as subscriber, patient, demographic,
      diagnosis or treatment data for the purpose of request for
      review, certification, notification or reporting the outcome of
      a health care services review

820   The HIPAA compliant transaction used to make a premium
      payment for insurance products. It can be used to order a
      financial institution to make a payment to a payee

834   The HIPAA compliant transaction used by employers, unions,
      government agencies, associations or insurance agencies to
      enroll members to a payer. The payer is a healthcare
      organization that pays claims, administers insurance or
      benefit or product

835   The HIPAA compliant transaction used to make a payment,
      send an Explanation of Benefits (EOB) remittance advice, or
      make a payment and send an EOB remittance advice only
      from a health insurer to a health care provider either directly
      or via a financial institution

837   The HIPAA compliant transaction used for used to submit
      health care claim billing information, encounter information,
      or both, except for retail pharmacy claims

                                                                               Revised – 20110929

997                          The HIPAA compliant transaction used to define the control
                             structures for a set of acknowledgments to indicate the
                             results of the syntactical analysis of the electronically encoded

1099                         A federally mandated tax form sent annually to the IRS and to
                             most providers that receive payments from FSSA. There are
                             no deductions from payments to 1099 providers

Accept                       To take or receive information

Access                       To retrieve information to inquire, read from, write to, modify
                             or communicate data or information, or to make use of any
                             system resources; See also Electronic Access

Accounts Payable (AP or      Record of the state’s legal obligation to pay a vendor,
A/P)                         provider or other entity with which the State does business

Accounts Receivable (AR or   Record of payments due to the state from providers, vendors,
A/R)                         members, or other entity with which the State does business

Accurate, Accuracy           Free from error

Ad Hoc Report                Report generated on an as-needed basis such as a legislative

Adhere                       To be in accordance with, without deviation

Adjudicate, adjudication     Process by which claims are subjected to edit checks, and
                             either denied, paid fully or paid partially. Suspended claims
                             which require further review are not considered adjudicated

Adjust                       To apply a debit or credit to an account

Advanced Planning            42 CFR 433.112 and Part 11 of the State Medicaid Manual
Document (APD)               requires obtaining of prior written approval from CMS for any
                             project the design, development, installation and/or
                             improvement of Medicaid Management Information Systems
                             (MMIS) where enhanced funding at the 90 percent rate is
                             requested regardless of the funding amount

Aggregate                    To sum a total of many heterogeneous things taken together

Alert                        Brief message or reminder generated by a system displayed
                             to designated users which triggers action. Alerts must be clear
                             to the end-user and contain directions or links to directions

                                                                           Revised – 20110929

                         on resolution of the alert trigger

Algorithm                Recursive computational procedure for solving a problem in a
                         finite number of steps

Analyze                  To examine methodically by separating into parts and
                         studying their interrelations

Applicant                Individual who has applied for services or assistance from
                         FSSA and has not yet been determined eligible

Apply                    To put into operation or effect

Approve                  To officially accept as satisfactory

Approved Communication   Any member, provider, contractor, vendor or other business
                         entity correspondence authorized by the State

Archive                  To maintain historical data from current data to be used for
                         research purposes

Assign                   To designate or mark for a specific purpose

Assistance               Aid, such as money or food, given to homeless and other
                         financially needy people

Associate                To bring together or to connect

Attach                   To fasten, to join together

Attribute                Specific items of data which can be collected for a class

Audit                    In claim processing, review and examination of records or
                         activities to ensure compliance with established policies and
                         operational procedures; an automatic validation procedure
                         that compares data on a claim with historical claim data, for
                         example duplicate checking; historical claim data can also be
                         defined as information on another line on the same claim;
                         Contrast with Edit

Audit Trail              Supplementary information that enables a reviewer to
                         identify each step of a process and its results

Authorization            Function of specifying access rights to resources, which is
                         related to information security and computer security in
                         general and to access control in particular

                                                                             Revised – 20110929

Authorize                  To grant authorization or clearance for

Authorized User            Individual selected by the State to access or to modify data
                           who has a security profile which defines data and information
                           for which they can access; the term is defined by the State in
                           each division

Automatic/Automatically    Executed by a process without human intervention

Balance                    To verify equality between the totals of two sides of an

Billing Provider           A provider of medical or medically related services or
                           equipment that submits claims for the services or equipment;
                           can be the same as the performing or rendering provider or it
                           can be a medical group or billing agent with a different name
                           and identifier

Binary Large Objects       Collection of binary (file formats containing more than text
(BLOBS)                    fields) data stored as a single entity in a database
                           management system; used to store images or other
                           multimedia files

Business Continuity Plan   A plan that specifies those activities performed daily to
(BCP)                      maintain service, consistency, and recoverability

Buy-In                     Process in which Agency pays the Medicare, Part A and/or
                           Part B premium for certain individuals who are eligible for

Calculate                  To determine by mathematical processes

Capture                    To obtain data by a system or process

Cascading Style Sheets     A design and layout standard for Web pages which provides
(CSS)                      an overall consistent look and feel to a website; there are
                           three parts to CSS the styles, their placement, and the fact
                           they can cascade

Categorize                 To distribute into groups according to kinds used in classifying
                           reporting groups

Centers for Medicare &     Federal Health and Human Services Agency (formerly called
Medicaid Services (CMS)    the Health Care Financing Administration or HCFA) that is
                           responsible for Medicare and Medicaid Programs

                                                                             Revised – 20110929

Certification               Under Part II of the State Medicaid Manual, States may
                            request CMS certification of their MMIS six months after the
                            system is put into production; CMS conducts an onsite visit
                            during which the State must provide evidence that the MMIS
                            has performed all of the requirements required by CMS and
                            specified in the MMIS RFP; once Certification is granted States
                            may request 75% enhanced Federal funding for the operation
                            of the MMIS

Change                      To transform or make something different from the original

Children's Special Health   Program which provides supplemental medical coverage to
Care Services (CSHCS)       help families of children who have serious, chronic medical
                            conditions, age birth to 21 years of age, who meet the
                            program’s financial and medical criteria, pay for treatment
                            related to their child’s condition

Claim                       Paper or electronic request for payment submitted by a fee-
                            for-service provider with expectation of payment for services

Claim Form                  Pre-printed sheet of paper on which a medical or medically
                            related provider can enter identification and service
                            information and submit for payment; claim forms used by
                            FSSA Administrations are CMS-1500s for physician and
                            practitioner services, UB-04s for inpatient and outpatient
                            institutional services, ADA Forms for dental services

Claims Processing           All functions necessary to adjudicate a claim. For example,
Functions                   Claim edits, audits, and pricing functions normally handled by
                            an automated Claims Processing System

Client                      Person eligible in a program administered by FSSA; also
                            known as a recipient, member, or enrollee in the Medicaid
                            environment; See Member

CMS-64                      A federally mandated report statement of expenditures for
                            which states are entitled to Federal reimbursement under
                            Title XIX and which reconciles the monetary advance made on
                            the basis of Form CMS-37 filed previously for the same
                            quarter; CMS-64 data is the basis for the federal matching
                            funds for the Medicaid program paid to Medicaid states

Code of Federal             The Federal Government published rules and guidelines which
Regulations (CFR)           States must follow to receive accreditation and funding for
                            federally sponsored programs; 45 CFR and Part II of the State

                                                                               Revised – 20110929

                            Medicaid Manual are the major Federal guidelines for the
                            procurement and implementation of a MMIS; 42 CFR and the
                            State Medicaid Manual are the major Federal guidelines for
                            State Medicaid Agencies

Code Set                    Character encoding system consists of a code that pairs each
                            character from a given repertoire with something else; group
                            of standard values for a particular data element; many code
                            sets, including values of HCPCS Procedure Codes, are
                            mandated by HIPAA

Commercial Off The Shelf    Computer application that may be purchased from vendors
(COTS)                      and immediately installed on system servers and accessed by
                            business users with only minor configuration; see Out of the Box

Communication               Includes artifacts such as letters, brochures, training, notices,
                            requests for additional information which is linguistically,
                            culturally, and competency appropriate

Companion Guide             Guide which defines the HIPAA compliant transaction set
                            standards for sending and interpreting Electronic Data
                            Interchange (EDI) transactions

Complete                    All required fields are populated; includes all necessary parts
                            or steps

Compliance/Compliant        Adherence to policies, procedures, guidelines, standards or
                            laws to which a business process is subject

Comply                      To act in accordance with a rule or standard

Configure                   To set up or arrange something in such a way that it is ready
                            for operation for a particular purpose

Configuration Management
Plan                     Unique identification, controlled storage, change control, and
                         status reporting of selected intermediate work products,
                         product components, and products during the life of a system

Consistent, Consistency     Free from variation or contradiction

Contact                     Interaction between an authorized entity and a member,
                            provider, or other designated entity; contact can be in-
                            person, by phone, or by letter or e-mail

Context                     Set of facts or circumstances that surround a situation or

                                                                              Revised – 20110929


Convert                      To change (something) into a different form

Copy                         To replicate

Cost Avoidance               Form of COB in which a payer refuses to pay a claim because
                             another carrier is primary and refers the claim to the other
                             carrier; Contrast with Pay and Chase

Create                       To make or to produce or bring about by a course of action

Crosswalk                    List that associates one set of values with another, for
                             example a crosswalk between J Procedure Codes and NDC

Current Procedural           Coding system, defined in the publication Current Procedural
Terminology (CPT)            Terminology, for medical procedures that allows for
                             comparability in pricing, billing, and utilization review; CPT
                             Codes appear within the HCPCS Procedure Code; See HCPCS
                             Procedure Codes

Data                         Coded representations of meaningful words, numbers, or
                             pictures typically in a computer system; Contrast with Process

Data Conversion Plan (DCP)   The activities needed to plan, develop, test, and coordinate all
                             data and file conversions

Data Flow                    Sequence in which data is collected, transferred, managed,
                             stored and used by users

Data Management Strategy     The State’s data management initiatives and best practices
(DMS)                        that provide the techniques, processes, and products to meet
                             the State’s need for timely and accurate information

Data Model                   Framework for the development of new enhanced application
                             for development of an accurate model or graphical
                             representation of information needs and business process

Data Warehouse               Repository for collection of data that provides information
                             about a particular subject; gathered from a variety of sources
                             and merged into a coherent whole, identified with a specific
                             time-period, data is stable in the environment with new data

Decision Support System      Software and databases designed to help people at all levels
(DSS)                        of an organization make decisions

                                                                                Revised – 20110929

Deduct                        To take one thing from another

Define                        To determine or identify the essential qualities of

Demonstrate                   To establish the validity of something as proof by example

Depict                        To represent with words

Derive                        To deduce

Detail Design Specification   Defines the software and hardware specifications

Detailed System Design        Document which describes how the system will function, the
(DSD)                         data to be maintained, and the procedures to be followed

Determine                     To decide by choice of alternatives or possibilities

Develop                       To produce by deliberate effort over time

Diagnosis Related Group       System to classify hospital cases into one of approximately
(DRG)                         500 groups, also referred to as DRGs, expected to have similar
                              hospital resource use, developed for Medicare as part of the
                              prospective payment system; DRGs are assigned by a
                              "grouper" program based on ICD diagnoses, procedures, age,
                              sex, discharge status, and the presence of complications or co
                              morbidities; utilized by FSSA to price inpatient claims for most
                              Indiana hospitals

Disaster Recovery Plan        A plan of action for before, during, and after a disruptive
(DRP)                         event

Disburse                      To pay out money

Display                       To present

Disposition (noun)            Settlement outcome of a case

Disposition (verb)            To make a decision

Distribute                    To divide among several or many

Division of Aging (DA)        FSSA division which serves older adults and individuals with
                              disabilities and their families, in need of human services,
                              resources, or support to attain employment and self-
                              sufficiency or to maintain independence

Division of Family            FSSA division which provides various tools to strengthen

                                                                                 Revised – 20110929

Resources (DFR)               families through services that focus on prevention, early
                              intervention, self-sufficiency, family support and preservation;
                              division which administers cash assistance, child care
                              assistance, food stamps, employment and training services for
                              low-income clients as well as Medicaid eligibility throughout
                              the state

Division of Mental Health     FSSA division which assists people with mental illness or
and Addiction (DMHA)          addiction who are uninsured or underinsured to receive
                              treatment and re-integrate into the community; operates six
                              state hospitals and partners with Indiana's CMHCs to provide
                              treatment in communities across Indiana

Documentation                 Written and/or graphic material that describes organizational
                              procedures and/or system processes

Drug Manufacturers            Corporations that manufacture prescription and over-the-
                              counter drugs; also provide rebates to State Medicaid
                              Agencies for drugs on pharmacy claims

Drug Rebate                   Program in which State Medicaid Agencies apply to drug
                              manufacturers for rebates for portions of payments that they
                              have made for legend and OTC drugs; requires drug
                              manufacturers to have a national rebate agreement with CMS
                              and pay quarterly rebates to the states in order for states to
                              receive Federal Medicaid coverage of their products

Drug Utilization Review       IC 12-15-35-8 “drug utilization review" or "DUR" means the
(DUR)                         program designed to measure and assess on a retrospective
                              and a prospective basis the proper use of outpatient drugs in
                              the Medicaid program As added by P.L.75-1992, SEC.19

Edit                          Automatic procedure which checks incoming data for
                              completeness, validity, and consistency; in claim processing,
                              edits are validation procedures that involve a single claim
                              rather than historical claim data; Contrast with Audit

Electronic Data Interchange A computer-to-computer exchange of business documents
(EDI)                       (data) in a standard format between trading partners; under
                            HIPAA standard electronic transactions are required when
                            submitting eligibility verification, claims, and other data to a
                            payer. The following transactions are required under HIPAA:

                                     NCPDP 5.1      Pharmacy claims
                                     270            Eligibility verification request

                                                                               Revised – 20110929

                                   271            Eligibility verification response
                                   276            Claim status request
                                   277            Claim status response
                                   278            Referral certification and authorization
                                   820            Premium payment
                                   834            Enrollment and Disenrollment
                                   835            Payment and remittance advice
                                   837D           Dental claim
                                   837I           Institutional claim
                                   837P           Professional claim

Electronic Fund Transfer     Method of transferring funds by means of electronic
(EFT)                        transactions rather than paper checks or warrants; EFT
                             payments from Medicaid Agencies to providers and health
                             plans are supported by HIPAA Transactions

Electronic Prescribing (e-   The transmission, using electronic media, of prescription or
prescribing or eRx)          prescription-related information between a prescriber,
                             dispenser, pharmacy benefit manager or health plan either
                             directly or through an intermediary, including an e-prescribing
                             network; E-Prescribing includes, but is not limited to, two-way
                             transmissions between the point of care and the dispenser

Eligibility                  Fulfillment of requirements and meeting of qualifications to
                             receive medical and/or social services; Contrast with

Eligibility Verification     Electronic system indicates to authorized entities whether or
System (EVS)                 not a person is eligible for benefits; See Medicaid Eligibility
                             Verification System

Eliminate                    To remove entirely

Email                        Electronic communication system for sending and receiving
                             messages electronically over a computer network with
                             individuals or groups on networked computers and computers
                             equipped for Internet access; facilitates electronic

Encounter                    Paper form or electronic transaction similar in format to a
                             claim but used for reporting with no expectation of payment;
                             submitted by health plans to Medicaid Agencies for reporting;
                             Contrast with Claim

                                                                               Revised – 20110929

Enroll                       To register formally as a participant or member

Ensure                       To guarantee or make sure of an occurrence

Enterprise Medicaid          The complete integration of multiple components of the
System (EMS)                 Medicaid system, incorporating the management of all
                             systems, including but not limited to the Core MMIS,
                             Pharmacy Benefit Manager, Data Warehouse, Third Party
                             Liability, Program Integrity

Enterprise Service Bus       A software architecture platform which provides integrated
(ESB)                        services via an events-driven and standards-based messaging

Entity                       Person or business equivalent

Establish                    To institute or bring into existence

Event                        Action or activity which occurs within a system and/or
                             network scope, inclusive of its boundaries

Exchange                     To give and receive

Execute                      To carry out or perform an action

Explanation of Benefits      Explanation of claim denial or reduced payment included on
(EOB)                        the provider’s Remittance Advice (RA); explanation of claim
                             denial or reduced payment included on the provider’s
                             Remittance Advice

Extensible Markup            Internet language that supports transmission of formatted
Language (XML)               data

Extract                      To select and separate

Extract, Transform, Load     Steps and underlying rules associated with moving data from
(ETL)                        one source into the repository

Facilitate                   To make an action or process easier

Family and Social Services   Umbrella agency responsible for administering most Indiana
Administration of Indiana    public assistance programs. FSSA consists of, but is not limited
(FSSA)                       to, the following offices or divisions CHIP, Office of the
                             Children’s Health Insurance Program; DCS, Division of
                             Children’s Services; DDRS, Division of Disability and
                             Rehabilitative Services; DFR, Division of Family Resources;
                             DMHA, Division of Mental Health and Addiction; IDA, Indiana

                                                                             Revised – 20110929

                             Division of Aging; OMPP, Office of Medicaid Policy and
                             Planning; FSSA is designated as the single State agency
                             responsible for administering the IHCP

Federal Financial            Distributions to States to pay for a percentage of every
Participation (FFP)          transaction (claim) that is processed through the MMIS; FFP is
                             also a CMS term used to describe the process of providing
                             States with federal funds to pay for the implementation and
                             maintenance of a MMIS

Federal Medical Assistance   Percentages for the state and federal share of expenditures
Percentages (FMAP)           for certain federal programs

Federally Qualified Health   Community health center or clinic that provides services to
Center (FQHC)                low-income people and meets federal qualifications for
                             receipt of Medicaid payments

Fee-for-Service (FFS)        Payment to providers based on services performed rather
                             than on the number of clients covered; Contrast with

Fiscal Agent (FA)            Entity contracted by the State to provide support primarily
                             responsible for processing claims, while also providing
                             services as required by the State such as member outreach,
                             provider outreach, training, claims processing, and other
                             operations as defined in the contract by the State to manage
                             and administer the Medicaid program

Follow                       To come behind or go in sequence

Form                         A template used to capture information

Format                       To determine the arrangement of (data) for storage and

Frequently Asked             Common acronym for answers to questions posted on a
Questions (FAQ)              portal

General System Design        Documents that define the activities required up to the
(GSD)                        interface

Generate                     To create or cause to be created

Generic Code Number          Code assigned to a generic drug category

Generic Sequence Number      Generic drug formulation identifier which groups drug

                                                                               Revised – 20110929

(GSN)                        products by unique variations

Health Insurance             Standardized mechanisms for electronic data interchange,
Portability and              security, and confidentiality of all healthcare-related data,
Accountability Act (HIPAA)   mandating standardized formats for all patient health,
                             administrative, and financial data; unique identifiers (ID
                             numbers) for each healthcare entity, including individuals,
                             employers, health plans and healthcare providers; and
                             security mechanisms to ensure confidentiality and data
                             integrity for any information that identifies an individual;
                             HIPAA Transaction and Code Set and Privacy and Security
                             mandates are of most significance to FSSA

Health Level 7 (HL7)         International set of standard formats for passing health care
                             data among computer systems; HL7 standards differ from the
                             standards mandated by HIPAA Transactions and Code Sets in
                             that they emphasize electronic messages about patients sent
                             between providers rather than communications between
                             providers and health care payers

Healthcare Common            Standard code set for Procedure Codes, including CPT codes,
Procedure Coding System      CDT codes and codes for other medical and medically related
(HCPCS)                      services; code set is still called HCPCS in spite of the federal
                             agency’s name change

Healthy Indiana Plan (HIP)   Program sponsored by the State of Indiana which provides a
                             more affordable health care choice to thousands of otherwise
                             uninsured individuals throughout Indiana; provides health
                             insurance for uninsured adult Hoosiers between the ages of
                             19 and 64 whose income is up to 200 percent of the federal
                             poverty level (FPL), and who are not otherwise eligible for

High dollar                  Claims for which the submitted charge exceeds a certain
                             State-defined threshold.

Hoosier Healthwise (HHW)     Federally approved Section 1915(b) waiver, implemented a
                             mandatory managed care program, Risk Based Managed Care
                             (RBMC), covering low income families, children and pregnant
                             women; program is managed by the State's contracted
                             Managed Care Organizations (MCOs)

Identify                     To select as matching a set of criteria

Impact                       To have an effect upon

                                                                               Revised – 20110929

Independent Verification     Process of checking that a product, service, or system meets
and Validation (IV&V)        specifications and that it fulfills its intended purpose and
                             meets contractual requirements

Indiana Administrative       Rules interpreting and adding detail to the laws in the Indiana
Code                         code

Indiana Code (IC)            Indiana code of laws for the State

Indiana Department of        IDOA centrally manages activities relating to state purchasing,
Administration (IDOA)        the vehicle and aviation fleet, state travel, real estate leases,
                             property disposition, and the Government Center Campus,
                             among others. In addition to agency support, the department
                             provides assistance to Minority and Women's Business
                             Enterprises interested in state contracting opportunities

Indiana Health Coverage      FSSA-administered program which provides State and Federal
Program (IHCP)               reimbursement for reasonable and necessary medical care for
                             persons meeting eligibility requirements; IHCP includes 590
                             Program, Hoosier Healthwise (including CHIP), traditional
                             Medicaid, Indiana Care Select, and Healthy Indiana Plan (HIP)

Indiana Medicaid             Technical companion guide, developed by the Indiana Health
Companion Guide              Coverage Plans, to supplement the adopted National
                             Electronic Data Interchange Transaction Set Implementation
                             Guide (IG) and assist application developers during the
                             development and implementation process

Indiana Office of Medicaid Office within the Indiana Families and Social Services
Policy and Planning (OMPP) Administration designated as the single state agency for
                           Medicaid to administer the Indiana Health Coverage
                           Programs; responsible for developing the policies and
                           procedures for the health plan programs, including programs
                           such as Hoosier Healthwise, Care Select, and Healthy Indiana

Indicate                     To point out or point to

Indiana Office of            An Indiana state agency established in 2005 to provide
Technology (IOT)             enterprise technology services to its partner state agencies

Information                  Data that has been verified to be accurate and timely, is
                             specified and organized for a purpose, is presented within a
                             context that gives it meaning and relevance, and leads to
                             increase in understanding or a decrease in uncertainty

                                                                                 Revised – 20110929

Information Technology          Set of concepts and best practice guidance for information
Infrastructure Library (ITIL)   technology (IT) service management

Initiate                        To trigger or prompt which causes an action to occur

Institute of Electrical and     Organization of technical professionals which has developed
Electronics Engineers (IEEE)    the industry standards for communications and networks
                                formats and specifications

Integrate, Integration          The concept of bringing together inputs, delivery,
                                management and organization of services related to
                                diagnosis, treatment, care, rehabilitation and health

Interactive Voice Response      Computerized equipment which replaces human telephone
System (IVRS or IVR)            operators, playing out recorded or synthesized messages,
                                instructing callers to press buttons or respond verbally to
                                access desired services, individuals, departments

Interfaces                      Interaction point at which electronic files are transferred from
                                one computer system to another

International Classification    Basic code set for medical diagnoses
of Diseases (ICD)

Internet                        Worldwide network of computer networks that uses
                                teleprocessing protocols to facilitate data transmission and
                                exchange, used throughout FSSA as a two-way information

Limit                           To restrict or confine

Link                            To connect one part or thing with another

Load                            Importation of data into a table or other defined structure

Load balancers                  Network devices, such as switches or routers, that take the
                                incoming traffic and spread it evenly across devices that are
                                providing the same service

Maintain                        To store information in order to update, delete, or change in a
                                central location, accessible as needed

Manage                          To organize or control business functions

Managed Care Entity (MCE)       A State-contracted individual or organization which provides
                                managed care services or program administration for

                                                                             Revised – 20110929

                            managed care services

Management and              Federally mandated MMIS subsystem that produces financial
Administrative Reporting    and utilization reports
Subsystem (MARS)

Match                       To compare as in compare data sets

Medicaid                    Medical assistance program described in Title XIX of the
                            federal Social Security Act; each state administers a separate
                            Medicaid Program that is financed by both federal matching
                            funds and state funds and is subject to federal review

Medicaid Fraud Control      An entity of state government, which conducts audits,
Unit                        investigations, and evaluations to determine if providers are
                            defrauding the Medicaid program

Medicaid Information        An initiative for a national framework to support improved
Technology Architecture     systems development and health care management for the
(MITA)                      Medicaid enterprise

Medicaid Management         Automated claims processing and information retrieval
Information System          system mandated by CMS for all Medicaid states which
(MMIS)                      includes an integrated group of procedures and computer
                            processing operations (subsystems) developed at the general
                            design level to meet principal objectives such as program
                            control and administrative costs; service to recipients,
                            providers and inquiries; operations of claims control and
                            computer capabilities; and management reporting for
                            planning and control

Medicaid Statistical        System which produces the annual State MSIS Report
Information System (MSIS)   providing summary data on Medicaid eligible, recipients, and
                            services, and on medical provider payments consisting of 14
                            sections which contain aggregate data broken down by
                            service types and demographic categories

Medicare                    Federally sponsored health insurance program for people
                            over 65 years old

Member                      Person eligible in a program administered by FSSA; also
                            known as a recipient, client, or enrollee in the Medicaid
                            environment; See Client

Metadata                    Data about data, data used to describe other data, usage

                                                                                Revised – 20110929

                               turns it into metadata

Metadata Management            Refers to the content, structure and designs necessary to
                               manage the vocabulary and other metadata which describes
                               statistical data, designs and processes; includes the
                               development of metadata models to define the content of
                               metadata within some context, building metadata registries
                               to organize the metadata defined in the model

Modify                         To make basic or fundamental changes

National Council for           Organization which maintains standard NDC and a standard,
Prescription Drug Programs     HIPAA compliant format for pharmacy claims

National Drug Code (NDC)       Standard code set used to identify legend and non-legend

National Provider Identifier   Standard provider identifier to be mandated by HIPAA in
(NPI)                          conjunction with Provider Taxonomy Codes

Notify                         To inform

Open                           To be able to launch

Optical Character              Electronic device which reads handwritten characters created
Recognition (OCR)              in a standard format and converts them to electronic data

Output                         Data going from a computer system in the form or a file,
                               electronic transaction, or report; Contrast with Input

Override                       To counteract the normal operation of

Over the Counter (OTC)         Drugs that may be sold to a consumer without a prescription
                               from a healthcare professional. For purposes of Indiana
                               Medicaid, a prescription is required for a covered OTC drug in
                               order for IHCP to reimburse for the product.

Participate                    To take part

Pay                            To discharge or settle an obligation, in healthcare often
                               thought of as the act of reimbursing for a rendered service

Payment                        The partial or complete discharge of an obligation by its
                               settlement in the form of the transfer of funds equal to the
                               monetary value of part or all of the obligation; Contrast with

                                                                             Revised – 20110929


Payment Error Reduction     Federal Program which attempts to identify common claim
and Measurement (PERM)      errors by sampling and reviewing data from Claim History so
                            that error rates can be reduced

Perform                     To act on so as to accomplish or bring to completion; execute

Pharmacy Benefit Manager    A third party administrator of prescription drug programs,
(PBM)                       primarily responsible for processing and paying prescription
                            drug claims. Additional responsibilities may include, but are
                            not limited to developing and maintaining the formulary,
                            contracting with pharmacies, and negotiating
                            discounts/rebates with drug manufacturers

Pharmacy Benefit            Those services provided by a Pharmacy Benefit Manager
Management, or Pharmacy     (PBM)
Benefit Management

Pharmacy Benefit            The system utilized by the Pharmacy Benefit Manager (PBM)
Management System           in providing services under this contract

Pharmacy Claims             Process for Pharmacy related claims payers to apply edits
Adjudication (PCA)          assigning an action such as deny, suspend, replace or monitor
                            when a claim is submitted

Point of Sale (POS)         Software which automates store operations of independent
Pharmacy Claim System       pharmacies, integrated with pharmacy dispensing systems

Portable Document Format    Widely used format for documents available on the Internet

Portal                      Platform which presents information from diverse sources in
                            a unified way

Preferred Drug List (PDL)   Listing of drugs for which providers may prescribe without
                            seeking prior authorization. Drugs not included on the PDL
                            require providers to obtain approval from the state Medicaid
                            agency prior to dispensing the drug

Premium                     Payment made to an insurance carrier in return for coverage

Primary Medical Provider    Medical provider who provides and coordinates medical care

                                                                               Revised – 20110929

(PMP)                       services for clients

Prior Authorization (PA)    Procedure for the office's prior review and authorization,
                            modification, or denial of payment for covered medical
                            services and supplies within Medicaid allowable charges
                            based upon medical reasonableness and necessity and other
                            criteria as described in 405 IAC 5-3. (Office of the Secretary of
                            Family and Social Services)

Privacy and Security        HIPAA component which mandates confidentiality of personal
                            medical information and secure maintenance of health care

Process                     To execute a series of functions designed to achieve a specific
                            result through to completion on a set of data in a computer
                            system. Processes can involve comparison, arithmetic and
                            logical operations, and decisions

Process Model               Framework describing the activities, functions, and processes
                            of an organization; defined in terms of their inputs and
                            outputs and accompany data models; a data model does not
                            reflect any action or flow of information, and presents only a
                            static view of data

Procurement                 The acquisition of appropriate goods and/or services at the
                            best possible total cost of ownership to meet the needs of the
                            purchaser in terms of quality and quantity, time, and location

Produce                     To make or cause to occur

Project Control Documents   Set of documents required to effectively manage a project,
(PCD)                       may vary depending on the type of project

Project Management Body     Book which presents a set of standard terminology and
of Knowledge (PMBOK)        guidelines for project management

Project Management          World’s leading not-for-profit membership association for the
Institute (PMI)             project management profession, supported by globally-
                            recognized standards and credentials, extensive research
                            program, and professional development opportunities

Project Management Office   Responsible for developing, administering and maintaining
(PMO)                       the Project Management approach that will govern the MMIS

Prospective Drug            IC 12-15-35-13 "Prospective DUR" means the part of the drug
Utilization Review (pro-    utilization review program that: (1) is to occur before the drug

                                                                              Revised – 20110929

DUR)                        is dispensed;
                            (2) is designed to screen for potential drug therapy problems
                            based on explicit and predetermined criteria and standards
                            that are developed on an ongoing basis with professional
                            input; and (3) is to provide for the counseling of recipients
                            about the proper use of drugs.
                            As added by P.L.75-1992, SEC.19

Protected Health            Individually identifiable health information transmitted or
Information (PHI)           maintained in any form or medium, which is held by a covered
                            entity or its business associate; under HIPAA, all health care
                            history and health condition information for an individual
                            must be protected from unauthorized release or
                            inappropriate use

Provide                     To make something available to

Provider                    An Indiana Medicaid-enrolled person, organization, or
                            institution who renders services to FSSA members

Quality Assurance (QA)      The planned and systematic activities implemented in a
                            quality system so that quality requirements for a product or
                            service will be fulfilled

Quality Purchase            A list of the State’s negotiated rates with software/hardware
Agreement (QPA)             vendors

Query                       Electronic request for information from the data maintained
                            by a computer system

Real-time                   Data sharing or processing data functions with immediate and
                            interactive response times as defined by the State, threshold
                            levels must be determined for each process

Receive                     To bring captured data into a system

Recipient Identification    Unique number assigned to an individual who is eligible for
Number (RID)                Assistance Programs services, currently assigned by the entity
                            responsible for determining eligibility (ICES)

Recognize                   To identify as something previously seen, known

Reconcile, Reconciliation   Process of comparing separate versions of the same data to
                            ensure that both versions are consistent with each other such
                            as client/member eligibility in MMIS reconciled with eligibility

                                                                                Revised – 20110929

                             in the entity responsible for determining eligibility (ICES)

Record (n)                   An account in permanent form of the known facts regarding
                             something or someone

Record (v)                   To compile the known facts regarding something or someone

Recovery Point Objective     The point in time to which you must recover data as defined
(RPO)                        by the EMS. This is generally a definition of what is
                             determined is an "acceptable loss” in a disaster situation

Recovery Time Objective      Duration of time and a service level within which a business
(RTO)                        process must be restored after a disaster (or disruption) in
                             order to avoid unacceptable consequences associated with a
                             break in business continuity. It includes the time for trying to
                             fix the problem without a recovery, the recovery itself, tests
                             and the communication to the users. Decision time for users’
                             representative is not included

Register                     To record

Reject                       To refuse

Relational Database          Database in which relations between information items are
                             explicitly specified as accessible attributes; in a relational
                             database the data are organized as a number of differently
                             sized tables

Relational Database          Sophisticated electronic file structure that optimizes the way
Management System            in which a system’s data is stored and accessed

Relational Database          Type of database management system that stores data in the
Management System            form of related tables

Remittance Advice (RA)       Paper document or electronic transaction which notifies
                             providers how claims have been adjudicated; RAs are typically
                             issued in association with claim payments

Report                       To give an account of

Repository                   Store of information regarding a business area including data
                             and meta data

Request for Proposal (RFP)   Document issued by a government agency which solicits
                             proposals for work by external entities; RFPs frequently
                             involve development and/or maintenance of computer

                                                                                 Revised – 20110929


Requirement Traceability     Table to trace from top level requirements to
Matrix                       implementation, and from top level requirements to test;
                             linking higher level requirements, design specifications, test
                             requirements, and code files

Resource                     A person, time or asset

Retain                       To keep for a period of time

Retention                    Holding data or information in a secure or intact manner for a
                             State defined length of time based on the business need

Retrieve                     To access information

Return on Investment (ROI)   Amount of income or cost savings expected from an

Review                       To look over or examine again

Rollback                     Ability to restore a system to a previous configuration

Route                        To send documents or materials to appropriate destinations

Schedule                     To plan for an activity or event

Send                         To dispatch or transmit information

Server Farms                 Collections of servers managed as a single entity

Set (Noun)                   Group of one or more similar entities

Set (Verb)                   To apply a pre-determined value or attribute

Software                     Electronic instructions that operate computers and related

Software Requirements        A comprehensive description of the required software
Specification (SRS)          performance capabilities including use cases

Specialty Pharmacy           Pharmacy services involving technologically advanced
Services                     pharmaceuticals that, in general, have specific preparation
                             and/or administration considerations attendant to their use,
                             are high cost, and are generally not provided by community
                             retail pharmacies

                                                                                Revised – 20110929

Stakeholder                    Person, group, or organization that has direct or indirect
                               interest in an organization because of the organization’s
                               effect on them, specifically the planning, design,
                               development, and implementation of a new PBM

Statement on Auditing          Defines the standards an auditor must employ in order to
Standards No. 70 (SAS-70)      assess the contracted internal controls of a service

State Maximum Allowable        A method of drug pricing that began in 1972 to help control
Cost (State MACs)              the cost of the pharmacy program. The SMAC process
                               identifies multi-source drugs (e.g., generic drugs) that have
                               actual acquisition costs below established reimbursement
                               rates to providers and adjusts reimbursement rates to make
                               them closer to the actual acquisition costs

State Medicaid Manual          The Federal document published by CMS that outlines all
                               mandatory and optional services States must consider as they
                               administer the Medicaid program. Part 11 of the SMM
                               includes regulations for the procurement certification and the
                               ongoing operation of the MMIS

Status                         Code defining a condition

Storage Area Network           Network that integrates different kinds of data storage in the
(SAN)                          infrastructure architecture

Store                          To keep for a period of time

Subject Matter Expert          Persons that are expert on a subject area

Submit                         To present or refer to others for decision, consideration

Success                        Favorable or desired outcome

Suggest                        To offer for consideration or action

Support                        To perform an action that assists in the performance of
                               another action, as in “support claim processing”

Surveillance and Utilization   Unit within FSSA that performs post-payment review to
Review (SUR)                   detect fraud, abuse, and inappropriate utilization or provision
                               of services

                                                                                 Revised – 20110929

System                        Organized set of communicating parts to serve a purpose

System Development Life       Conceptual model used in project management that describes
Cycle (SDLC)                  the stages involved in an information system development
                              project, from an initial feasibility study through maintenance
                              of the completed application

System Requirements           Structured collection of information which is comprised of the
Specification (SyRS)          requirements of the system

Test (noun)                   Particular process or method for assessing the quality or
                              correctness of a result

Test (Verb)                   Applying pre-defined criteria to determine if a process result
                              is correct

Third Party Liability (TPL)   An entity other than the recipient or the Medicaid program
                              that may have a contractual obligation to pay for medical
                              services rendered to the recipient

Threshold                     Value above which something is true or will take place and
                              below which it is not or will not take place

Timing                        The regulation of occurrence, pace, or coordination to achieve
                              a desired effect

Title XIX                     Portion of the Federal Social Security Act that covers Medicaid

Track                         To quantitatively and qualitatively follow the status of an
                              action, typically by defined set of identifiers

Trading Partner               External entity with which business is conducted, typically
                              formalized via a trading partner agreement

Transfer                      To move from one place to another

Translate                     To change from one form or medium into another

Transmit                      To send data from one source to another

Update                        To add, change, or delete the value of a field or set of fields

Use                           To put into action or service

User                          Refers to individual who has been designated to have access
                              to data and information

                                                                           Revised – 20110929

Utilize                    To make use of

Validate                   To confirm the level of completion, accuracy and quality of

Value                      To establish payment amounts by using all appropriate
                           methods of pricing

Vendor                     Any individual, business, or entity that signs an agreement
                           with the State to perform the obligations under the terms
                           specified in a contract; responsible for the performance of any
                           obligations and shall not be relieved by the non-performance
                           of any subcontractor

Wide Area Network (WAN)    Combination of hardware, software, cables and access points
                           designed to support the sharing of data between users who
                           are located in multiple physical facilities across a large
                           geographic area

Work Breakdown Structure   Decomposition of a project into smaller components defining
(WBS)                      a project’s distinct work segments in a way that helps
                           organize and define the total work scope of the project


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