Glossary

A Commercial MCO is a health maintenance organization, an eligible organization with a contract under §1876 or a Medicare-Choice organization; a provider sponsored organization, or any other private or public organization, which meets the requirements of §1902(w). These MCOs provide comprehensive services to commercial and/or Medicare enrollees, as well as Medicaid enrollees.

A facility that provides the following services:

• Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharge from inpatient treatment at a mental health facility,
• 24 hour a day emergency care services,
• Day treatment, other than partial hospitalization services, or psychosocial rehabilitation services,
• Screening for patients considered for admission to State mental health facilities to determine the appropriateness of such admission, and
• Consultation and education services.

A place where Medicare patients can go to receive partial hospitalization services.

(See Grievance.)

A statement, oral or written, alleging that a provider or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services.

Under HIPAA, this is the date by which a covered entity must comply with a standard, an implementation specification, or a modification. This is usually 24 months after the effective data of the associated final rule for most entities, but 36 months after the effective data for small health plans. For future changes in the standards, the compliance date would be at least 180 days after the effective data, but can be longer for small health plans and for complex changes.

A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

A MCO is a health maintenance organization, an eligible organization with a contract under §1876 or a Medicare-Choice organization; a provider sponsored organization or any other private or public organization, which meets the requirements of §1902(w). These MCOs provides comprehensive services to both commercial and/or Medicare, as well as Medicaid enrollees.

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.

A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation.