Procedure that gives providers a chance to communicate any misconduct related to federal health care agencies whereby the provider may have lesser restitution than had the information not been revealed. Also called voluntary disclosure protocol.

Document created by the facility that shows annual costs and expenses incurred in treating Medicare patients. Medicare gathers the reimbursement information from this report for Medicare services (e.g., ambulatory surgery, end-stage renal disease, laboratory, orthotics, outpatient diagnostic services, prosthetics, radiology). The Uniform Bill (UB-04) billing data must be accurate because it affects the facility’s reimbursement received through the PS & R reporting system and cost-report settlement process.

Information collected through a survey or focus group of providers who participate in the Medicaid program and have provided services to enrolled Medicaid beneficiaries. The state or a contractor of the state may conduct the survey.

Automated voice-response system that allows the provider to use the telephone to obtain checkwrite, claim, and prior authorization information for services rendered through the Medi-Cal program and several other state programs.

Method that identifies providers and follows all contacts made to correct problems (e.g., provider’s eligibility, medical necessity issue, repeat billing abusers).

Formerly known as provider identification number (PIN). It is a carrier-assigned number that every facility, physician, clinic, or organization uses that renders services to patients when submitting insurance claims. It is issued to a provider by the insurance carrier or Medicare fiscal intermediary and allows the physician or patient to receive reimbursement for claims filed to the contractor. Also referred to as a legacy number. PINs have been replaced with the national provider identifiers (NPIs). See national provider identifier (NPI).

Group of doctors, hospitals, and other health care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. This type of managed care plan is run by the doctors and providers themselves and not by an insurance company. Also called provider health plan or provider-sponsored network (PSN).