Glossary

Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare. This is not the same as fraud.

A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.

A provision that any person has a right, enforceable in court, of access of
federal agency records, except to the extent that such records, or portions
thereof, are protected from disclosure by one of nine exemptions or by one
of three special law enforcement record exclusions.

A law that requires the U.S. Government to give out certain information to the public when it receives a written request. FOIA applies only to records of the Executive Branch of the Federal Government, not to those of the Congress or Federal courts, and does not apply to state governments, local governments, or private groups.

An exhaustive list of possible outcomes for a variable, and the associated probability of each outcome. The sum of the probabilities of all possible outcomes from a frequency distribution is 100 percent.

The plan or Primary Care Case Manager is paid for providing services to enrollees through a combination of capitation and fee for service reimbursements.

A plan is paid for providing services to enrollees solely through capitation.

For the purposes of this umbrella SOW, a full PSC is one that performs all of the fundamental activities contained in Section 3, General Requirements, under a Task Order.

Designation that all the elements within all the accreditation standards for which the accreditation organization has been approved by CMS have been surveyed and fully met or have otherwise been determined to be acceptable without significant adverse findings, recommendations, required actions or corrective actions.

Used when no comparable, existing test is available. Carrier specific amounts are used to establish a national limitation amount for the following year.