Medicaid Basics

There is a lot technical jargon when dealing with Medicaid. Below you'll find a glossary of terms to use a reference as needed.

Aggregator - A company that collects data from one or more sources, provides some value added processing, and then repackages the results in useful form.

CDS/SFC - Consumer Directed Services / Structured Family Care - Medicaid waiver program that has a family member designated as a caregiver providing care to their loved one. 

Diagnosis Codes / Dx Codes - Used as a tool to group and identify diseases, disorders, symptoms, etc. Most systems and companies will use the ICD-10 diagnosis codes. These are updated annually in October of each year.

EIN - Employer Identification Number

HCPCS Codes (Procedure Codes) - The Healthcare Common Procedure Coding System is a set of standardized codes that are used to report medical procedures and services to Medicare, Medicaid, and other health insurance programs. 

ICD-10 - International Classification of Diseases 10th edition. The international standard for medical coding designed by the World Health Organization.

MCO - A Managed Care Organization is a health plan with a group of providers working together to give health services to its members. MCOs often have contacts with state Medicaid agencies to deliver Medicaid benefits. 

NPI - National Provider Identifier. A 10 digit number issued to health care providers.

Prior Authorization - A document that outlines the service and treatments available to a client. These often have service periods that need to be renewed. 

Provider ID - A state assigned unique identifier for those providing Medicaid or Medicare services. Often confused with a NPI. 

Quantized Rate - A billing term. Generally, a set dollar amount over a 15 or 60 minute period.

Waiver Program - Medicaid waivers are for individuals with disabilities or chronic health conditions that allow for healthcare professionals to provide care in a person's home instead of a long-term care facility. Medicaid waivers provide money that can be used for in-home or community care.