Working group of individuals administered by the Blue Cross and Blue Shield Association. It is responsible for maintaining specific coding schemes used in the X12 transaction set such as claim adjustment reason codes, claim status category codes, and claim status codes.

Provide health care services to those in a community.

Method of structure and coordination encompassing medical facilities, health care services, and reimbursement methods to provide health care.

Former name of the federal agency within the Department of Health and Human Services (DHHS) established to administer and oversee Medicare, Medicaid, and State Children’s Health Insurance Programs, as well as other governmental health programs. This agency is now called Centers for Medicare and Medicaid Services (CMS) . See Centers for Medicare and Medicaid Services (CMS) .

Health care professionals, generally registered nurses, who are located at TRICARE Service Centers to act as liaison between military and civilian providers, verify eligibility, determine availability of services, coordinate care, facilitate the transfer of records, and perform first level medical review. This health care specialist helps TRICARE beneficiaries and providers with preauthorizations of medical services.

Employer-sponsored benefit that allows a fixed amount of pretax wages to be set aside for qualified expenses such as child care or uncovered medical expenses. Money in these accounts cannot be rolled over from year to year.

Kind of association certified by the Department of Workers’ Compensation to provide managed medical care within the workers’ compensation system.

Type of managed care organization that contracts with Centers for Medicare and Medicaid Services (CMS) to provide Medicare-eligible Part B medical services to enrollees. In return for a monthly premium, plus any applicable deductible or copayment, all or most of an individual’s physician services are provided by the HCPP. The HCPP pays for all services it has arranged for (and any emergency services) whether provided by its own physicians or its contracted network of physicians. If a member enrolled in an HCPP chooses to receive services that have not been arranged for by the HCPP, he or she is liable for any applicable Medicare deductible and/or coinsurance amounts, and any balance would be paid by the regional Medicare carrier.