Section IV

SECTION IV - GLOSSARY
400.000 11-1-23
AAFP American Academy of Family Physicians
AAP American Academy of Pediatrics
ABESPA Arkansas Board of Examiners in Speech-Language Pathology and
Audiology
ABHSCI Adult Behavioral Health Services for Community Independence
ACD Augmentative Communication Device
ACIP Advisory Committee on Immunization Practices
ACES Arkansas Client Eligibility System
ACS Alternative Community Services
ADDT Adult Developmental Day Treatment
ADE Arkansas Department of Education
ADH Arkansas Department of Health
ADL Activities of Daily Living
AFDC Aid to Families with Dependent Children (cash assistance program
replaced by the Transitional Employment Assistance (TEA) program)
AHEC Area Health Education Centers
ALF Assisted Living Facilities
ALS Advance Life Support
ALTE Apparent Life-Threatening Events
AMA American Medical Association
APD Adults with Physical Disabilities
ARS Arkansas Rehabilitation Services
ASC Ambulatory Surgical Centers
ASHA American Speech-Language-Hearing Association
BIPA Benefits Improvement and Protection Act
BLS Basic Life Support
CARF Commission on Accreditation of Rehabilitation Facilities
CCRC Children’s Case Review Committee
CFA One Counseling and Fiscal Agent
CFR Code of Federal Regulations
CLIA Clinical Laboratory Improvement Amendments
CME Continuing Medical Education
CMHC Community Mental Health Center
CMS Centers for Medicare and Medicaid Services
COA Council on Accreditation
CON Certification of Need
CPT Physicians’ Current Procedural Terminology

Section IV-1
 Section IV

CRNA Certified Registered Nurse Anesthetist

CSHCN Children with Special Health Care Needs
CSWE Council on Social Work Education
D&E Diagnosis and Evaluation
DAAS Division of Aging and Adult Services
DBS Division of Blind Services (currently named Division of Services for the
Blind)
DCFS Division of Children and Family Services
DCO Division of County Operations
DD Developmentally Disabled
DDS Developmental Disabilities Services
DHS Department of Human Services
DLS Daily Living Skills
DME Durable Medical Equipment
DMHS Division of Mental Health Services
DMS Division of Medical Services (Medicaid)
DOS Date of Service
DPSQA Division of Provider Services and Quality Assurance
DRG Diagnosis Related Group
DRS Developmental Rehabilitative Services
DDSCES Developmental Disabilities Services Community and Employment Support
DSB Division of Services for the Blind (formerly Division of Blind Services)
DSH Disproportionate Share Hospital
DURC Drug Utilization Review Committees
DYS Division of Youth Services
EIDT Early Intervention Day Treatment
EAC Estimated Acquisition Cost
EFT Electronic Funds Transfer
EIN Employer Identification Number
EOB Explanation of Benefits
EOMB Explanation of Medicaid Benefits. EOMB may also refer to Explanation of
Medicare Benefits.
EPSDT Early and Periodic Screening, Diagnosis, and Treatment
ESC Education Services Cooperative
FEIN Federal Employee Identification Number
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
GME Graduate Medical Education
GUL Generic Upper Limit

Section IV-2
 Section IV

HCBS Home and Community Based Services

HCPCS Healthcare Common Procedure Coding System
HDC Human Development Center
HHS The Federal Department of Health and Human Services
HIC Number Health Insurance Claim Number
HIPAA Health Insurance Portability and Accountability Act of 1996
HMO Health Maintenance Organization
IADL Instrumental Activities of Daily Living
ICD International Classification of Diseases
ICF/IID Intermediate Care Facility for Individuals with Intellectual Disabilities
ICN Internal Control Number
IDEA Individuals with Disabilities Education Act
IDG Interdisciplinary Group
IEP Individualized Educational Program
IFSP Individualized Family Service Plan
IMD Institution for Mental Diseases
IPP Individual Program Plan
IUD Intrauterine Devices
JCAHO Joint Commission on Accreditation of Healthcare Organization
LAC Licensed Associate Counselor
LCSW Licensed Certified Social Worker
LEA Local Education Agencies
LMFT Licensed Marriage and Family Therapist
LPC Licensed Professional Counselor
LPE Licensed Psychological Examiner
LSPS Licensed School Psychology Specialist
LTC Long Term Care
MAC Maximum Allowable Cost
MAPS Multi-agency Plan of Services
MART Medicaid Agency Review Team
MEI Medicare Economic Index
MMIS Medicaid Management Information System
MNIL Medically Needy Income Limit
MPPPP Medicaid Prudent Pharmaceutical Purchasing Program
MSA Metropolitan Statistical Area
MUMP Medicaid Utilization Management Program
NBCOT National Board for Certification of Occupational Therapy
NCATE North Central Accreditation for Teacher Education

Section IV-3
 Section IV

NDC National Drug Code

NET Non-Emergency Transportation Services
NF Nursing Facility
NPI National Provider Identifier
OBRA Omnibus Budget Reconciliation Act
OHCDS Organized Health Care Delivery System
OBHS Outpatient Behavioral Health Services
OTC Over the Counter
PA Prior Authorization
PAC Provider Assistance Center
PASSE Provider-led Arkansas Shared Savings Entity Program
PCP Primary Care Physician
PERS Personal Emergency Response Systems
PHS Public Health Services
PIM Provider Information Memorandum
PL Public Law
POC Plan of Care
POS Place of Service
PPS Prospective Payment System
PRN Pro Re Nata or “As Needed”
PRO Professional Review Organization
ProDUR Prospective Drug Utilization Review
QIDP Qualified Intellectual Disabilities Professional
QMB Qualified Medicare Beneficiary
RA Remittance Advice. Also called Remittance and Status Report
RFP Request for Proposal
RHC Rural Health Clinic
BID Beneficiary Identification Number
RSPD Rehabilitative Services for Persons with Physical Disabilities
RSYC Rehabilitative Services for Youth and Children
RTC Residential Treatment Centers
RTP Return to Provider
RTU Residential Treatment Units
SBMH School-Based Mental Health Services
SD Spend Down
SFY State Fiscal Year
SMB Special Low-Income Qualified Medicare Beneficiaries
SNF Skilled Nursing Facility

Section IV-4
 Section IV

SSA Social Security Administration

SSI Supplemental Security Income
SURS Surveillance and Utilization Review Subsystem
TCM Targeted Case Management
TEA Transitional Employment Assistance
TEFRA Tax Equity and Fiscal Responsibility Act
TOS Type of Service
TPL Third Party Liability
UPL Upper Payment Limit
UR Utilization Review
VFC Vaccines for Children
VRS Voice Response System
Accommodation A type of hospital room, e.g., private, semiprivate, ward, etc.
Activities of Daily Personal tasks that are ordinarily performed daily and include eating,
Living (ADL) mobility/transfer, dressing, bathing, toileting, and grooming
Adjudicate To determine whether a claim is to be paid or denied
Adjustments Transactions to correct claims paid in error or to adjust payments from a
retroactive change
Admission Actual entry and continuous stay of the beneficiary as an inpatient to an
institutional facility
Affiliates Persons having an overt or covert relationship such that any individual
directly or indirectly controls or has the power to control another individual
Agency The Division of Medical Services
Aid Category A designation within SSI or state regulations under which a person may
be eligible for public assistance
Aid to Families with A Medicaid eligibility category
Dependent Children
(AFDC)
Allowed Amount The maximum amount Medicaid will pay for a service as billed before
applying beneficiary coinsurance or co-pay, previous TPL payment, spend
down liability, or other deducted charges
American Medical National association of physicians
Association (AMA)
Ancillary Services Services available to a patient other than room and board. For example:
pharmacy, X-ray, lab, and central supplies
Arkansas Client A state computer system in which data is entered to update assistance
Eligibility System eligibility information and beneficiary files
(ACES)
Attending Physician See Performing Physician.
Automated Eligibility Online system for providers to verify eligibility of beneficiaries and submit
Verification Claims claims to fiscal agent
Submission (AEVCS)
Base Charge A set amount allowed for a participating provider according to specialty

Section IV-5
 Section IV

Beneficiary Person who meets the Medicaid eligibility requirements, receives an ID

card, and is eligible for Medicaid services (formerly recipient)
Benefits Services available under the Arkansas Medicaid Program
Billed Amount The amount billed to Medicaid for a rendered service
Buy-In A process whereby the state enters into an agreement with the
Medicaid/Medicare and the Social Security Administration to obtain
Medicare Part B (and part A when needed) for Medicaid beneficiaries who
are also eligible for Medicare. The state pays the monthly Medicare
premium(s) on behalf of the beneficiary.
Caregiver An individual who has responsibility for the protection, in-home care, or
custody of a Medicaid enrollee as a result of assuming the responsibility
by contract.
Care Plan See Plan of Care (POC).
Case Head An adult responsible for an AFDC or Medicaid child
Categorically Needy All individuals receiving financial assistance under the state’s
approved plan under Title I, IV-A, X, XIV, and XVI of the Social Security
Act or in need under the state’s standards for financial eligibility in such a
plan
Centers for Medicare Federal agency that administers federal Medicaid funding
and Medicaid
Services
Child Health Services Arkansas Medicaid’s Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program
Children with Chronic A Title V Children with Special Health Care Needs Program administered
Health Conditions by the Arkansas Division of Developmental Disabilities Services to
(CHC) provide medical care and service coordination to children with chronic
physical illnesses or disabilities.
Claim A request for payment for services rendered
Claim Detail See Line Item.
Clinic (1) A facility for diagnosis and treatment of outpatients. (2) A group
practice in which several physicians work together
Coinsurance The portion of allowed charges the patient is responsible for under
Medicare. This may be covered by other insurance, such as Medi-Pak or
Medicaid (if entitled). This also refers to the portion of a Medicaid covered
inpatient hospital stay for which the beneficiary is responsible.
Contract Written agreement between a provider of medical services and the
Arkansas Division of Medical Services. A contract must be signed by
each provider of services participating in the Medicaid Program.
Co-pay The portion of the maximum allowable (either that of Medicaid or a third-
party payer) that the insured or beneficiary must pay
Cosmetic Surgery Any surgical procedure directed at improving appearance but not
medically necessary
Covered Service Service which is within the scope of the Arkansas Medicaid Program
Current Procedural A listing published annually by AMA consisting of current medical terms
Terminology and the corresponding procedure codes used for reporting medical
services and procedures performed by physicians

Section IV-6
 Section IV

Credit Claim A claim transaction which has a negative effect on a previously processed
claim.
Crossover Claim A claim for which both Titles XVIII (Medicare) and XIX (Medicaid) are
liable for reimbursement of services provided to a beneficiary entitled to
benefits under both programs
Date of Service Date or dates on which a beneficiary receives a covered service.
Documentation of services and units received must be in the beneficiary’s
record for each date of service.
Deductible The amount the Medicare beneficiary must pay toward covered benefits
before Medicare or insurance payment can be made for additional
benefits. Medicare Part A and Part B deductibles are paid by Medicaid
within the program limits.
Debit Claim A claim transaction which has a positive effect on a previously processed
claim
Denial A claim for which payment is disallowed
Department of Health Federal health and human services agency
and Human Services
(HHS)
Department of State human services agency
Human Services
(DHS)
Dependent A spouse or child of the individual who is entitled to benefits under the
Medicaid Program
Diagnosis The identity of a condition, cause, or disease
Diagnostic Admission Admission to a hospital primarily for the purpose of diagnosis
Disallow To subtract a portion of a billed charge that exceeds the Medicaid
maximum or to deny an entire charge because Medicaid pays Medicare
Part A and B deductibles subject to program limitations for eligible
beneficiaries
Discounts A discount is defined as the lowest available price charged by a provider
to a client or third-party payer, including any discount, for a specific
service during a specific period by an individual provider. If a Medicaid
provider offers a professional or volume discount to any customer, claims
submitted to Medicaid must reflect the same discount.
Example: If a laboratory provider charges a private physician or clinic a
discounted rate for services, the charge submitted to Medicaid for the
same service must not exceed the discounted price charged to the
physician or clinic. Medicaid must be given the benefit of discounts and
price concessions the lab gives any of its customers.
Duplicate Claim A claim that has been submitted or paid previously or a claim that is
identical to a claim in process
Durable Medical Equipment that (1) can withstand repeated use and (2) is used to serve
Equipment a medical purpose. Examples include a wheelchair or hospital bed.
Early and Periodic A federally mandated Medicaid program for eligible individuals under the
Screening, Diagnosis, age of twenty-one (21). See Child Health Services.
and Treatment
(EPSDT)

Section IV-7
 Section IV

Education When an individual is required to possess a bachelor’s degree, master’s

Accreditation degree, or a Ph.D. degree in a specific profession. The degree must be
from a program accredited by an organization that is approved by the
Council for Higher Education Accreditation (CHEA).
Electronic Signature An electronic or digital method executed or adopted by a party with the
intent to be bound by or to authenticate a record, which is: (a) Unique to
the person using it; (b) Capable of verification; (c) Under the sole control
of the person using it; and (d) Linked to data in such a manner that if the
data are changed the electronic signature is invalidated. An Electronic
Signature method must be approved by the DHS Chief Information Officer
or his or her designee before it will be accepted. A list of approved
electronic signature methods will be posted on the state Medicaid
website.
Eligible (1) To be qualified for Medicaid benefits. (2) An individual who is qualified
for benefits
Eligibility File A file containing individual records for all persons who are eligible or have
been eligible for Medicaid
Emergency Services Inpatient or outpatient hospital services that a prudent layperson with an
average knowledge of health and medicine would reasonably believe are
necessary to prevent death or serious impairment of health and which,
because of the danger to life or health, require use of the most accessible
hospital available and equipped to furnish those services.
Source: 42 U.S. Code of Federal Regulations (42 CFR) and §424.101.
Error Code A numeric code indicating the type of error found in processing a claim
also known as an “Explanation of Benefits (EOB) code” or a “HIPAA
Explanation of Benefits (HEOB) code”
Estimated Acquisition The estimated amount a pharmacy actually pays to obtain a drug
Cost
Experimental Surgery Any surgical procedure considered experimental in nature
Explanation of A statement mailed once per month to selected beneficiaries to allow
Medicaid Benefits them to confirm the Medicaid service which they received
(EOMB)
Family Planning Any medically approved diagnosis, treatment, counseling, drugs, supplies,
Services or devices prescribed or furnished by a physician, nurse practitioner,
certified nurse-midwife, pharmacy, hospital, family planning clinic, rural
health clinic (RHC), Federally Qualified Health Center (FQHC), or the
Department of Health to individuals of child-bearing age for purposes of
enabling such individuals freedom to determine the number and spacing
of their children.
Field Audit An activity performed whereby a provider’s facilities, procedures, records,
and books are audited for compliance with Medicaid regulations and
standards. A field audit may be conducted on a routine basis, or on a
special basis announced or unannounced.
Fiscal Agent An organization authorized by the State of Arkansas to process Medicaid
claims
Fiscal Agent A private business firm which has entered into a contract with the
Intermediary Arkansas Department of Human Services to process Medicaid claims
Fiscal Year The twelve-month period between settlements of financial accounts

Section IV-8
 Section IV

Generic Upper Limit The maximum drug cost that may be used to compute reimbursement for
(GUL) specified multiple-source drugs unless the provisions for a Generic Upper
Limit override have been met. The Generic Upper Limit may be
established or revised by the Centers for Medicare and Medicaid Services
(CMS) or by the State Medicaid Agency.
Group Two (2) or more persons. If a service is a “group” therapy or other group
service, there must be two (2) or more persons present and receiving the
service.
Group Practice A medical practice in which several practitioners render and bill for
services under a single pay-to provider identification number
Healthcare Common Federally defined procedure codes
Procedure Coding
System (HCPCS)
Health Insurance Number assigned to Medicare beneficiaries and individuals eligible for
Claim Number SSI
Hospital An institution that meets the following qualifications:
 Provides diagnostic and rehabilitation services to inpatients
 Maintains clinical records on all patients
 Has by-laws with respect to its staff of physicians
 Requires each patient to be under the care of a physician, dentist,
or certified nurse-midwife
 Provides 24-hour nursing service
 Has a hospital utilization review plan in effect
 Is licensed by the State
 Meets other health and safety requirements set by the Secretary
of Health and Human Services
Hospital-Based A physician who is a hospital employee and is paid for services by the
Physician hospital
ID Card An identification card issued to Medicaid beneficiaries and ARKids First-B
participants containing encoded data that permits a provider to access the
card-holder’s eligibility information
Individual A single person as distinguished from a group. If a service is an
“individual” therapy or service, there may be only one (1) person present
who is receiving the service.
Inpatient A patient, admitted to a hospital or skilled nursing facility, who occupies a
bed and receives inpatient services.
In-Process Claim A claim that suspends during system processing for suspected error
(Pending Claim) conditions such as: all processing requirements appear not to be met.
These conditions must be reviewed by the Arkansas Medicaid fiscal agent
or DMS and resolved before processing of the claim can be completed.
See Suspended Claim.
Inquiry A request for information
Institutional Care Care in an authorized private, non-profit, public, or state institution or
facility. Such facilities include schools for the deaf, or blind and
institutions for individuals with disabilities.
Instrumental Activities Tasks which are ordinarily performed on a daily or weekly basis and
of Daily Living (IADL) include meal preparation, housework, laundry, shopping, taking
medications, and travel/transportation

Section IV-9
 Section IV

Intensive Care Isolated and constant observation care to patients critically ill or injured
Interim Billing A claim for less than the full length of an inpatient hospital stay. Also, a
claim that is billed for services provided to a particular date even though
services continue beyond that date. It may or may not be the final bill for
a particular beneficiary’s services.
Internal Control The unique 13-digit claim number that appears on a Remittance Advice
Number (ICN)
International A diagnosis coding system used by medical providers to identify a
Classification of patient’s diagnosis or diagnoses on medical records and claims
Diseases
Investigational Any product that is considered investigational or experimental and that is
Product not approved by the Food and Drug Administration. The Arkansas
Medicaid Program does not cover investigational products but does cover
routine standard of care associated with qualifying clinical trials.
Julian Date Chronological date of the year, 001 through 365 or 366, preceded on a
claims number (ICN) by a two-digit-year designation. Claim number
example: 03231 (August 19, 2003).
Length of Stay Period of time a patient is in the hospital. Also, the number of days
covered by Medicaid within a single inpatient stay.
Limited Services An agreement for a specific period of time not to exceed twelve (12)
Provider Agreement months, which must be renewed in order for the provider to continue to
participate in the Title XIX Program.
Line Item A service provided to a beneficiary. A claim may be made up of one (1)
or more line items for the same beneficiary. Also called a claim detail.
Long Term Care An office within the Arkansas Division of Medical Services responsible for
(LTC) nursing facilities
Long Term Care A nursing facility
Facility
Maximum Allowable The maximum drug cost which may be reimbursed for specified multi-
Cost (MAC) source drugs. This term is interchangeable with generic upper limit.
Medicaid Provider A unique identifying number assigned to each provider of services in the
Number Arkansas Medicaid Program, required for identification purposes
Medicaid The automated system utilized to process Medicaid claims
Management
Information System
(MMIS)
Medical Assistance A section within the Arkansas Division of Medical Services responsible for
Section administering the Arkansas Medical Assistance Program
Medically Needy Individuals whose income and resources exceed the levels for assistance
established under a state or federal plan for categorically needy, but are
insufficient to meet costs of health and medical services

Section IV-10
 Section IV

Medical Necessity All Medicaid benefits are based upon medical necessity. A service is
“medically necessary” if it is reasonably calculated to prevent, diagnose,
correct, cure, alleviate, or prevent the worsening of conditions that
endanger life, cause suffering or pain, result in illness or injury, threaten to
cause or aggravate a handicap, or cause physical deformity or
malfunction and if there is no other equally effective (although more
conservative or less costly) course of treatment available or suitable for
the beneficiary requesting the service. For this purpose, a “course of
treatment” may include mere observation or (where appropriate) no
treatment at all. The determination of medical necessity may be made by
the Medical Director for the Medicaid Program or by the Medicaid
Program Quality Improvement Organization (QIO). Coverage may be
denied if a service is not medically necessary in accordance with the
preceding criteria or is generally regarded by the medical profession as
inappropriate or ineffective unless objective clinical evidence
demonstrates circumstances making the service necessary.
Mis-Utilization Any usage of the Medicaid Program by any of its providers or
beneficiaries which is not in conformance with both State and Federal
regulations and laws (including, but not limited to, fraud, abuse, and
defects in level and quality of care)
National Drug Code The unique 11-digit number assigned to drugs which identifies the
manufacturer, drug, strength, and package size of each drug
National Provider A standardized unique health identifier for health care providers for use in
Identifier (NPI) the health care system in connection with standard transactions for all
covered entities. Established by the Centers for Medicare & Medicaid
Services, HHS, in compliance with HIPAA Administrative Simplification –
45 CFR Part 162.
Non-Covered Services not medically necessary, services provided for the personal
Services convenience of the patient or services not covered under the Medicaid
Program
Nonpatient An individual who receives services, such as laboratory tests, performed
by a hospital, but who is not a patient of the hospital
Nurse Practitioner A professional nurse with credentials that meet the requirements for
licensure as a nurse practitioner in the State of Arkansas
Outpatient A patient receiving medical services, but not admitted as an inpatient to a
hospital
Over-Utilization Any over usage of the Medicaid Program by any of its providers or
beneficiaries not in conformance with professional judgment and both
State and Federal regulations and laws (including, but not limited to, fraud
and abuse)
Participant A provider of services who: (1) provides the service, (2) submits the claim
and (3) accepts Medicaid’s reimbursement for the services provided as
payment in full
Patient A person under the treatment or care of a physician or surgeon, or in a
hospital
Payment Reimbursement to the provider of services for rendering a Medicaid-
covered benefit
Pay-to Provider A person, organization, or institution authorized to receive payment for
services provided to Medicaid beneficiaries by a person or persons who
are a part of the entity

Section IV-11
 Section IV

Pay-to Provider A unique identifying number assigned to each pay-to provider of services
Number (Clinic/Group/Facility) in the Arkansas Medicaid Program or the pay-to
provider group’s assigned National Provider Identifier (NPI). Medicaid
reports provider payments to the Internal Revenue Service under the
Employer Identification Number “Tax ID” linked in the Medicaid Provider
File to the pay-to provider identification number.
Per Diem A daily rate paid to institutional providers
Performing Physician The physician providing, supervising, or both, a medical service and
claiming primary responsibility for ensuring that services are delivered as
billed
Person Any natural person, company, firm, association, corporation, or other legal
entity
Place of Service A nationally approved two-digit numeric code denoting the location of the
(POS) patient receiving services
Plan of Care A document utilized by a provider to plan, direct, or deliver care to a
patient to meet specific measurable goals; also called care plan, service
plan, or treatment plan
Postpayment The review of services, documentation, and practice after payment
Utilization Review
Practitioner An individual who practices in a health or medical service profession
Prepayment The review of services, documentation, and practice patterns before
Utilization Review payment
Prescription A health care professional’s legal order for a drug which, in accordance
with federal or state statutes, may not be obtained otherwise; also, an
order for a particular Medicaid covered service
Prescription Drug A drug which, in accordance with federal or state statutes, may not be
(RX) obtained without a valid prescription
Primary Care A physician responsible for the management of a beneficiary’s total
Physician (PCP) medical care. Selected by the beneficiary to provide primary care
services and health education. The PCP will monitor on an ongoing basis
the beneficiary’s condition, health care needs and service delivery, be
responsible for locating, coordinating, and monitoring medical and
rehabilitation services on behalf of the beneficiary, and refer the
beneficiary for most specialty services, hospital care, and other services.
Prior Approval The approval for coverage and reimbursement of specific services prior to
furnishing services for a specified beneficiary of Medicaid. The request
for prior approval must be made to the Medical Director of the Division of
Medical Services for review of required documentation and justification for
provision of service.
Prior Authorization The approval by the Arkansas Division of Medical Services, or a designee
(PA) of the Division of Medical Services, for specified services for a specified
beneficiary to a specified provider before the requested services may be
performed and before payment will be made. Prior authorization does
not guarantee reimbursement.
Procedure Code A five-digit numeric or alpha numeric code to identify medical services
and procedures on medical claims
Professional A physician’s interpretation or supervision and interpretation of laboratory,
Component X-ray, or machine test procedures

Section IV-12
 Section IV

Profile A detailed view of an individual provider’s charges to Medicaid for health

care services or a detailed view of a beneficiary’s usage of health care
services
Provider A person, organization, or institution enrolled to provide and be
reimbursed for health or medical care services authorized under the State
Title XIX Medicaid Program
Provider Identification A unique identifying number assigned to each provider of services in the
Number Arkansas Medicaid Program or the provider’s assigned National Provider
Identifier (NPI), when applicable, that is required for identification
purposes
Provider Relations The activity within the Medicaid Program which handles all relationships
with Medicaid providers
Quality Assurance Determination of quality and appropriateness of services rendered
Quality Improvement A Quality Improvement Organization (QIO) is a federally mandated review
Organization organization required of each state’s Title XIX (Medicaid) program. The
QIO monitors hospital and physician services billed to the state’s
Medicare intermediary and the Medicaid program to assure high quality,
medical necessity, and appropriate care for each patient’s needs.
Railroad Claim The number issued by the Railroad Retirement Board to control payments
Number of annuities and pensions under the Railroad Retirement Act. The claim
number begins with a one- to three-letter alphabetic prefix denoting the
type of payment, followed by six (6) or nine (9) numeric digits.
Referral An authorization from a Medicaid enrolled provider to a second Medicaid
enrolled provider. The receiving provider is expected to exercise
independent professional judgment and discretion, to the extent permitted
by laws and rules governing the practice of the receiving practitioner, and
to develop and deliver medically necessary services covered by the
Medicaid program. The provider making the referral may be a physician
or another qualified practitioner acting within the scope of practice
permitted by laws or rules. Medicaid requires documentation of the
referral in the beneficiary’s medical record, regardless of the means the
referring provider makes the referral. Medicaid requires the receiving
provider to document the referral also, and to correspond with the
referring provider regarding the case when appropriate and when the
referring provider so requests.
Registry records The review of one (1) or more database systems maintained by a state
check agency that contain information relative to the suitability of a person to be
a caregiver.
Reimbursement The amount of money remitted to a provider
Rejected Claim A claim for which payment is refused
Relative Value A weighting scale used to relate the worth of one (1) surgical procedure to
any other. This evaluation, expressed in units, is based upon the skill,
time, and the experience of the physician in its performance.
Remittance A remittance advice
Remittance Advice A notice sent to providers advising the status of claims received, including
(RA) paid, denied, in-process, and adjusted claims. It includes year-to-date
payment summaries and other financial information.
Reported Charge The total amount submitted in a claim detail by a provider of services for
reimbursement

Section IV-13
 Section IV

Retroactive Medicaid Medicaid eligibility which may begin up to three (3) months prior to the
Eligibility date of application provided all eligibility factors are met in those months
Returned Claim A claim which is returned by the Medicaid Program to the provider for
correction or change to allow it to be processed properly
Routine Standard of Effective for items and services furnished on or after 01/01/2022,
Care Associated with Medicaid covers the routine costs of qualifying clinical trials, as such costs
Qualifying Clinical are defined below, as well as reasonable and necessary items and
Trials services used to diagnose and treat complications arising from
participation in all clinical trials. All other Medicaid rules apply.
Routine costs of a clinical trial include all items and services that are
otherwise generally available to Medicaid beneficiaries (i.e., there exists a
benefit category, it is not statutorily excluded, and there is not a national
non-coverage decision) that are provided in either the experimental or the
control arms of a clinical trial except:
The investigational item or service, itself unless otherwise covered outside
of the clinical trial;
 Items and services provided solely to satisfy data collection and
analysis needs and that are not used in the direct clinical
management of the patient (e.g., monthly CT scans for a condition
usually requiring only a single scan); and
 Items and services customarily provided by the research sponsors
free-of-charge for any enrollee in the trial.
Routine costs in clinical trials include:
 Items or services that are typically provided absent a clinical trial
(e.g., conventional care);
 Items or services required solely for the provision of the
investigational item or service (e.g., administration of a
noncovered chemotherapeutic agent), the clinically appropriate
monitoring of the effects of the item or service, or the prevention
of complications; and
 Items or services needed for reasonable and necessary care
arising from the provision of an investigational item or service, for
the diagnosis or treatment of complications.
Sanction Any corrective action taken against a provider
Screening The use of quick, simple, medical procedures carried out among large
groups of people to sort out apparently well persons from those who may
have a disease or abnormality and to identify those in need of more
definitive examination or treatment
Signature The person’s original signature or initials. The person’s signature or
initials may also be recorded by an electronic or digital method, executed,
or adopted by the person with the intent to be bound by or to authenticate
a record. An electronic signature must comply with Arkansas Code
Annotated § 25-31-101-105, including verification through an electronic
signature verification company and data links invalidating the electronic
signature if the data is changed.
Single State Agency The state agency authorized to administer or supervise the administration
of the Medicaid Program on a statewide basis

Section IV-14
 Section IV

Skilled Nursing A nursing home, or a distinct part of a facility, licensed by the Office of
Facility (SNF) Long-Term Care as meeting the Skilled Nursing Facility Federal/State
licensure and certification regulations. A health facility which provides
skilled nursing care and supportive care on a 24-hour basis to residents
whose primary need is for availability of skilled nursing care on an
extended basis.
Social Security A federal agency which makes disability and blindness determinations for
Administration (SSA) the Secretary of the HHS
Social Security Claim The account number used by SSA to identify the individual on whose
Number earnings SSA benefits are being paid. It is the Social Security Account
Number followed by a suffix, sometimes as many as three (3) characters,
designating the type of beneficiary (e.g., wife, widow, child, etc.).
Source of Care A hospital, clinic, physician, or other facility which provides services to a
beneficiary under the Medicaid Program
Specialty The specialized area of practice of a physician or dentist
Spend Down (SD) The amount of money a beneficiary must pay toward medical expenses
when income exceeds the Medicaid financial guidelines. A component of
the medically needy program allows an individual or family whose income
is over the medically needy income limit (MNIL) to use medical bills to
spend excess income down to the MNIL. The individual(s) will have a
spend down liability. The spend down column of the remittance advice
indicates the amount which the provider may bill the beneficiary. The
spend down liability occurs only on the first day of Medicaid eligibility.
Status Report A remittance advice
Supplemental A program administered by the Social Security Administration. This
Security Income (SSI) program replaced previous state administered programs for aged, blind,
or individuals with disabilities (except in Guam, Puerto Rico, and the
Virgin Islands). This term may also refer to the Bureau of Supplemental
Security Income within SSA which administers the program.
Suspended Claim An “In-Process Claim” which must be reviewed and resolved
Suspension from An exclusion from participation for a specified period
Participation
Suspension of The withholding of all payments due to a provider until the resolution of a
Payments matter in dispute between the provider and the state agency
Termination from A permanent exclusion from participation in the Title XIX Program
Participation
Third Party Liability A condition whereby a person or an organization, other than the
(TPL) beneficiary or the state agency, is responsible for all or some portion of
the costs for health or medical services incurred by the Medicaid
beneficiary (e.g., a health insurance company, a casualty insurance
company, or another person in the case of an accident, etc.).
Utilization Review The section of the Arkansas Division of Medical Services which performs
(UR) the monitoring and controlling of the quantity and quality of health care
services delivered under the Medicaid Program
Void A transaction which deletes
Voice Response Voice-activated system to request prior authorization for prescription
System (VRS) drugs and for PCP assignment and change
Ward An accommodation of five (5) or more beds

Section IV-15
 Section IV

Withholding of A reduction or adjustment of the amounts paid to a provider on pending

Payments and subsequently due payments
Worker’s A type of Third-Party Liability for medical services rendered as the result
Compensation of an on-the-job accident or injury to a beneficiary for which the
employer’s insurance company may be obligated under the Worker’s
Compensation Act

Section IV-16