Any federal or state health insurance program that receives funds via the Medicaid legislation with the intent to provide additional health services to Medicaid recipients.

Organization under contract to the state to process claims for a state Medicaid program.

Federal program created by the Deficit Reduction Act of 2005 to track and prevent Medicaid fraud. Government contractors will review the actions of those seeking payment from Medicaid, conduct audits, identify overpayments, and educate providers and others on program integrity and quality of care.

Prepaid health plan that provides comprehensive services to Medicaid beneficiaries but not to commercial or Medicare enrollees. Also called Medicaid-only managed care organization (MCO) .

System approved by the Centers for Medicare and Medicaid Services (CMS) that supports the operation of the Medicaid program. It includes the following types of subsystems or files: recipient eligibility, Medicaid provider, claims processing, pricing, Surveillance and Utilization Review System (SURS), Management and Administrative Reporting Subsystem (MARS), and potentially encounter processing. The objectives of this system and its enhancements include the Title XIX program control and administrative costs, service to recipients and providers, answers to inquiries, operations of claims control and computer capabilities, and management reporting for planning and control.

State division that is responsible for administering federal and state policies and overseeing the state’s Medicaid program.

Person who, under the direction of a physician, performs various routine administrative and nontechnical clinical tasks in a hospital, clinic, or other medical facility. See administrative medical assistant and clinical medical assistant .