Glossary

Contractor reviews of Medicare claims to ensure that the service was necessary and appropriate.

The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your State law allows it), and how much to charge you for that insurance.

Services or supplies that:are proper and needed for the diagnosis or treatment of your medical condition,are provided for the diagnosis, direct care, and treatment of your medical condition,meet the standards of good medical practice in the local area, andaren’t mainly for the convenience of you or your doctor.

The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) permitted the Centers for Medicare & Medicaid Services (CMS) to consolidate the Fiscal Intermediary (Part A) and Contractor (Part B) systems into a new system administered by Medicare Administrative Contractors (MACs), covering both Part A and Part B claims in one or more geographic jurisdictions.

A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.

Health insurance available under Medicare Part A and Part B through the traditional fee-forservicepayment system.

A notice you get after your doctor files a claim for Part A services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN). (See Explanation of Medicare Benefits; Medicare Summary Notice.)

A private company that contracts with Medicare to pay Part B bills.

A Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)