Glossary

A legislative program during the early 1970s that limited price increases.

A software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission.

Logic within the Standard Claims Processing System (or PSC Supplemental Edit Software) that selects certain claims, evaluates or compares information on the selected claims or other accessible source, and depending on the evaluation, takes action on the claims, such as pay in full, pay in part, or suspend for manual review.

Producing the expected results of this SOW, defined in section 1.B., Purpose of Contract.

Under HIPAA, this is the date that a final rule is effective, which is usually 60 days after it is published in the Federal Register.

Activities performed effectively with minimum of waste or unnecessary effort, or producing a high ratio of results to resources.

Public, private, formal, and informal programs and support systems, government laws, and finding ways to meet the needs of the elderly, including: housing, home care, pensions, Social Security, long-term care, health insurance, and elder law.

Your decision to join or leave the Original Medicare Plan or a Medicare+Choice plan.

Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare+Choice plan. There are four types of election periods in which you may join and leave Medicare health plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.

• Annual Election Period: The Annual Election Period is the month of November each year. Medicare health plans enroll eligible beneficiaries into available health plans during the month of November each year. Starting in 2002, this is the only time in which all Medicare+Choice health plans will be open and accepting new members.
• Initial Coverage Election Period: The three months immediately before you are entitled to Medicare Part A and enrolled in Part B. If you choose to join a Medicare health plan during your Initial Coverage Election Period, the plan must accept you. The only time a plan can deny your enrollment during this period is when it has reached its member limit. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP).
• Special Election Period: You are given a Special Election Period to change Medicare+Choice plans or to return to Original Medicare in certain situations, which include: You make a permanent move outside the service area, the Medicare+Choice organization breaks its contract with you or does not renew its contract with CMS; or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).
• Open Enrollment Period: If the Medicare health plan is open and accepting new members, you may join or enroll in it. If a health plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.

The exchange of business information by electronic means.