Section 471-3-002 - DEFINITIONS002.01ADJUDICATE. To determine whether a claim or adjustment is to be paid or denied.002.02BALANCE BILLING. Billing the Department or client any amount after a provider has agreed to accept a payment as payment in full.002.03CASUALTY INSURER. An insurance policy which pays for medical care as a result of an accident, incident, injury, disability, or disease; for example, automobile insurance, homeowners insurance, commercial liability insurance, product liability insurance, workers compensation, etc.002.04CLAIM. A request for payment for services rendered or supplied by a provider to a client.002.05 CLEARINGHOUSE. An entity which processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction and receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard or nonstandard data content for the receiving entity.002.06CLIENT ASSIGNMENT OF RIGHTS. The client's action to assign to the Department his or her rights, and the rights of any other eligible individuals on whose behalf he or she has legal authority under state law to assign such rights, to medical support and to payment for medical care from any liable third party, except Part A and B of Medicare. Assignment of rights is accomplished by signing the Medicaid application.002.07DENIAL. Non-payment of services or benefits by Nebraska Medicaid.002.08HEALTH INSURER. Any group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, as amended in 1993, an entity offering a service benefit plan, or a health maintenance organization (HMO).002.09HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS). The system which contains the national codes adopted by the federal Secretary of Health and Human Services and includes American Medical Association's Current Procedural Terminology (CPT) Level I procedure codes and Level 2 procedure codes.002.10INDIAN. An individual, defined at 25 United States Code (U.S.C.) sections 1603(c), 1603(f), and 1679(b), or who has been determined eligible, as an Indian, pursuant to 42 Code of Federal Regulations (C.F.R.) 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian Health Service, an Indian Tribe, Tribal Organization, Urban Indian Organization, or through referral under Contract Health Services.002.11INDIAN HEALTH CARE PROVIDER. A health care program, including contract health services, operated by the Indian Health Service or by an Indian Tribe, Tribal Organization, or Urban Indian Organization as those terms are defined 25 U.S.C. 1603.002.12MEDICARE ADVANTAGE PLAN. Coordinated care plans meeting Medicare C standards, including health maintenance organizations (HMO), Provider Sponsored Organizations (PSO), Preferred Providers Organizations (PPO), religious fraternal benefits plans, and other coordinated care plans. Individuals eligible for Medicare Part A and Part B may choose to enroll in a Medicare Advantage Plan instead of the traditional Medicare fee-for-service program. Part B only enrollees are ineligible.002.13MEDICAL SUPPORT. The obligation of a non-custodial parent to provide health insurance or pay for medical care ordered by a court or administrative body established under state law.002.14MEDICARE AND MEDICAID DUALLY ELIGIBLE INDIVIDUAL. Individuals dually eligible for Medicare and Medicaid during the same period of time.002.15MEDICARE PART A. A federal program, created by the Social Security Act of 1965, to provide coverage of hospital, skilled nursing, and certain other services for Medicare beneficiaries.002.16MEDICARE PART B. A federal program, created by the Social Security Act of 1965, to provide coverage of practitioner, durable medical equipment, supplies, and certain other services for Medicare beneficiaries.002.17MEDICARE PART D. A federal program, also known as the Medicare prescription drug benefit. This voluntary program provides coverage of certain drugs, classes of drugs, or therapeutic categories of drugs and certain medical supplies or equipment for all Medicare beneficiaries, including those beneficiaries also eligible for Medicaid. Clients who are dually eligible for Medicare and Medicaid are automatically enrolled in Part D.002.18MEDICARE PART D PLAN. An entity, approved by the Centers for Medicare and Medicaid Services, to provide coverage of Medicare Part D drugs and certain medical supplies for Medicare beneficiaries.002.19MEDICARE PART D DRUG. Any drug, class of drugs, or therapeutic category of drugs which is not a Medicare Part D Excluded drug, regardless of formulary, prior approval, or tier status by the Part D Plan.002.20MEDICARE PART D EXCLUDED DRUG. Any drug, class of drugs, or therapeutic category of drugs which is specifically excluded from coverage under the Medicare Modernization Act of 2003 and amendments to the act, or as defined by federal regulations implementing the Medicare Modernization Act.002.21 MEDICARE PART D SUPPLIES OR EQUIPMENT. Insulin syringes, needles, alcohol swabs, gauze, and other products covered by Medicare Part D Plans.002.22NON-CUSTODIAL PARENT. Parent who does not reside with a child but has a legal responsibility to provide court or administrative ordered medical support for the child.002.23PAY AND CHASE. A recovery method in which Medicaid pays the total amount allowed under Nebraska Medicaid and then seeks to recover from liable third party resources.002.24PREFERRED PROVIDER ORGANIZATION (PPO). Fee for service plan with an incentive to use network providers to provide care for the plan's subscribers. Patients may see physicians outside the network but at reduced payment rate. A copayment may be required on certain services.002.25PRIVATE INSURER. This includes: (A) Any commercial insurance company offering health or casualty insurance to individuals or groups, including both experience-related and indemnity contracts;(B) Any profit or nonprofit prepaid plan offering either medical services or full or partial payment for the diagnosis and treatment of an injury, disease, or disability; and(C) Any organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments for services, including self-insured and self-funded plans, under section 607(1) of the Employee Retirement Income Security Act.002.26REMITTANCE ADVICE. The third party plan's statement of payment for services. When billing Medicaid, this statement may be provided as a paper or electronic remittance advice, and must include the insurance company name, patient name, dates of service, charges, and amount paid. If charges were denied by insurance, the portion of the remittance advice showing the denial reason must be included.002.27SHARE OF COST. The amount of the client's income which must be obligated or paid for medical care before Medicaid payment can be made.002.28STANDARD TRANSACTION. An electronic transaction which complies with the applicable standard adopted under federal law.002.29SUBROGATION. Right of the state to stand in place of the client in collection of third party resources.002.30THIRD PARTY RESOURCE. Any individual, entity, or program which is, or may be, contractually or legally liable to pay all or part of the cost of any medical service furnished to an individual.002.31TRANSACTION. The exchange of information between two parties to carry out financial or administrative activities related to health care.002.32TRADING PARTNER AGREEMENT. An agreement related to the electronic exchange of information.002.33WAIVER CLAIM. A claim for which the Department has applied and received a cost avoidance waiver from the Centers for Medicare and Medicaid Services, or claims which are mandated to have cost avoidance waived under 42 CFR 433.139.002.34WARRANT. A paper check or electronic funds transfer.471 Neb. Admin. Code, ch. 3, § 002
Amended effective 6/6/2022