Medicare Advantage and Prescription Drug Plans December 28 ...
Medicare Advantage and Prescription Drug Plans December 28 ...
Medicare Advantage and Prescription Drug Plans December 28 ...
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Plan Communications User Guide Appendices, Version 6.3<br />
Term<br />
Dual Eligible<br />
Election Period<br />
Enrollment<br />
Enrollment Process<br />
Exception<br />
Failed Payment Reply<br />
Codes<br />
Failed Transaction<br />
Formulary<br />
Gentran<br />
Hospice<br />
Logoff<br />
Logon<br />
Lookup field<br />
Medicaid<br />
Managed Care<br />
Organization (MCO)<br />
Menu<br />
Network Data Mover<br />
(NDM)<br />
MicroStrategy<br />
Nursing Home<br />
Certifiable (NHC)<br />
Off-cycle<br />
Definition<br />
Individuals entitled to both <strong>Medicare</strong> <strong>and</strong> Medicaid benefits<br />
Time periods during which a Beneficiary may elect to join, change, or leave<br />
<strong>Medicare</strong> Part C <strong>and</strong>/or Part D <strong>Plans</strong>. These periods are fully defined in CMS<br />
Enrollment <strong>and</strong> Disenrollment guidance for Part C <strong>and</strong> D <strong>Plans</strong> available on the<br />
Web at: http://www.cms.gov/home/medicare.asp under “Eligibility <strong>and</strong><br />
Enrollment.”<br />
A record submitted when a Beneficiary joins an MCO or a drug plan.<br />
A process in which a Plan submits a request to enroll in a Plan, change<br />
enrollment, or disenroll.<br />
A transaction that is unprocessed due to errors or internal inconsistencies.<br />
Codes used for the Failed Payment Reply Report that identify incomplete<br />
payment calculations for a beneficiary.<br />
A transaction that did not complete due to problems with the format of the<br />
transaction or internal system problems.<br />
The medications covered by an MA organization or prescription drug plan.<br />
The Gentran servers provide Electronic Data Interchange (EDI) capabilities<br />
between CMS <strong>and</strong> CMS business partners. These servers provide MARx with<br />
transaction files from the <strong>Plans</strong>, <strong>and</strong> provide the <strong>Plans</strong> with MARx reports.<br />
A health facility for the terminally ill.<br />
The method of exiting an online system.<br />
The method for gaining entry to an online system.<br />
A field that provides a list of possible values. When the user clicks on the<br />
“binocular” button next to the field, a window pops up with a list of values for<br />
that field. Clicking on one of those values closes the pop-up window <strong>and</strong> the<br />
field is filled with the value chosen.<br />
A jointly funded, Federal-State health insurance program for certain low-income<br />
<strong>and</strong> needy people. It covers approximately 36 million individuals including<br />
children, the aged, blind, <strong>and</strong>/or disabled, <strong>and</strong> people eligible to receive<br />
Federally assisted income maintenance payments.<br />
A type of contract under which CMS pays for each member, based on<br />
demographic characteristics <strong>and</strong> health status; also referred to as Risk. In a Risk<br />
contract, the MCO accepts the risk if the payment does not cover the cost of<br />
services, but keeps the difference if the payment is greater than the cost of<br />
services. Risk is managed through a membership where the high costs for very<br />
sick members are balanced by the lower cost for a larger number of relatively<br />
healthy members.<br />
A horizontal list of items at the top of a screen. Clicking on a menu item<br />
displays a screen <strong>and</strong> may display a submenu of items corresponding to the<br />
selected menu item.<br />
Software used for transmitting <strong>and</strong> receiving data; replaced by Connect:Direct.<br />
A tool used for generating <strong>and</strong> viewing st<strong>and</strong>ard <strong>and</strong> ad hoc reports.<br />
A code that reflects the relative frailty of an individual. NHC Beneficiaries are<br />
those whose condition would ordinarily require nursing home care. The code is<br />
only acceptable for certain social health maintenance organization (SHMO)-<br />
type <strong>Plans</strong>.<br />
A retroactive transaction awaiting CMS approval because its effective date is<br />
too old for automatic acceptance.<br />
<strong>December</strong> <strong>28</strong>, 2012 A-2 Glossary <strong>and</strong> List of Abbreviations<br />
<strong>and</strong> Acronyms