Medical Billing Terms M: Medicare Part B, MPFS and Medigap

Also called Part A; hospital insurance; Medicare hospital coverage

Definition

Medicare Part A is hospital insurance. It generally helps cover inpatient hospital stays, including inpatient psychiatric hospital care, along with skilled nursing facility care, hospice, and some home health care.

Why it matters

Outpatient therapy and psychiatry visits are usually Part B, not Part A, so the two are billed differently. Knowing the part helps a biller pick the right claim form and payer rules.

Illustrative example

A patient's inpatient psychiatric stay is a Part A service, while the follow-up therapy visits are Part B.

Related termsMedicareMedicare Part BMedicare AdvantageMedicare Administrative Contractor (MAC)Guide: Medicare behavioral health billing

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Also called Part B; medical insurance

Definition

The part of Medicare that covers outpatient services, including mental health visits, with an annual deductible and coinsurance.

Why it matters

The main path for outpatient behavioral health billing to Medicare.

Illustrative example

A therapist's claim goes to the MAC for Part B processing.

Related termsMedicareDeductibleCoinsuranceGuide: Medicare behavioral health billing

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Medicare Learning Network (MLN)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Also called Part B deductible; Part B 20 percent coinsurance; Medicare cost sharing

Definition

Under Medicare Part B, the patient generally pays an annual deductible and then coinsurance, typically 20 percent of the Medicare-approved amount for covered outpatient services.

Why it matters

Providers collect the patient's share and bill a secondary payer, such as Medigap, for what it covers. The deductible amount is set each year by CMS.

Illustrative example

A patient with Part B and a Medigap plan owes coinsurance on a therapy visit, and the Medigap plan pays that share.

Related termsMedicare Part BMedigapCoinsuranceDeductibleGuide: Medicare behavioral health billing

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Medicare Learning Network (MLN)checked 10/9/26

CategoriesMedicare & Medicaid TermsPatient Financial Responsibility Terms

Also called Part D; Medicare prescription drug coverage

Definition

Medicare Part D is Medicare's outpatient prescription drug coverage, offered through private plans.

Why it matters

Prescribers care about it because each plan has its own formulary, prior authorization rules, and step therapy. Those rules affect which psychiatric medications a patient can get.

Illustrative example

A psychiatrist's patient cannot fill a medication because the Part D plan requires prior authorization.

Related termsMedicarePrior AuthorizationStep TherapyPsychiatristGuide: Medicare behavioral health billing

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Also called PFS look-up tool; PFS lookup; Medicare fee schedule search

Definition

The Medicare Physician Fee Schedule Look-Up Tool is a CMS online tool for finding the Medicare payment amount and status indicators for a code in a given locality.

Why it matters

Practices use it to learn Medicare's rate for a code and to compare a commercial contract to Medicare. Amounts change each year.

Illustrative example

A practice looks up the 2026 amount for 90834 in its locality to check a payer's offered rate.

Related termsMedicare Physician Fee Schedule (MPFS)Geographic Practice Cost Index (GPCI)Relative Value Unit (RVU)Fee Schedule

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid TermsPayment & Reimbursement

Also called PFS; Medicare fee schedule; physician fee schedule

Definition

The CMS payment schedule for physician and other practitioner services, including psychotherapy, using relative value units and a conversion factor. It is updated on a regular cycle.

Why it matters

Many commercial and Medicaid rates are set as a percentage of the Medicare fee schedule.

Illustrative example

A payer contract pays a percentage of the current Medicare fee schedule for 90834.

Related termsRelative Value Unit (RVU)Conversion FactorFee Schedule

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Physician Fee Schedulechecked 10/9/26

CategoriesMedicare & Medicaid TermsPayment & Reimbursement

Also called MSP; QMB SLMB QI; Medicare Savings Program

Definition

Medicare Savings Programs are state Medicaid programs that help some people with limited income pay Medicare costs, such as premiums and, for some groups, deductibles and coinsurance. Qualified Medicare Beneficiary is one such program.

Why it matters

A provider generally may not bill a QMB patient for Medicare cost sharing, so check status before billing the patient.

Illustrative example

A biller sees QMB on an eligibility check and does not bill the patient for coinsurance.

Related termsQualified Medicare Beneficiary (QMB)Dual EligibleCoinsuranceBalance Billing

Reference sourceCMS (Centers for Medicare & Medicaid Services)Medicaid.govchecked 10/9/26

CategoriesMedicare & Medicaid TermsEligibility & Benefits

Also called MSP; Medicare secondary rules

Definition

Rules that determine when another insurer, such as an employer plan, must pay before Medicare.

Why it matters

Billing Medicare first when it should be secondary can create overpayments.

Illustrative example

A working aged patient's employer plan is primary and Medicare is secondary.

Related termsCoordination of Benefits (COB)Crossover ClaimMedicare AdvantageGuide: Secondary claims

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid TermsEligibility & Benefits

Also called MSSP; Shared Savings Program

Definition

A Medicare program that lets ACOs share in savings when they meet quality and cost benchmarks.

Why it matters

Shapes how many practices are paid and measured.

Illustrative example

A practice joins an MSSP ACO.

Related termsAccountable Care Organization (ACO)Shared Savings

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesValue-Based Care TerminologyMedicare & Medicaid Terms

Also called MSN; Medicare statement to patient; Medicare quarterly notice

Definition

A Medicare Summary Notice is a statement Medicare sends to beneficiaries, generally every three months, that lists the services billed to Medicare and what Medicare paid.

Why it matters

It is the patient's document, not the provider's remittance advice. Patients may call with questions about an MSN, and a biller can compare it with the provider's ERA.

Illustrative example

A patient calls about a charge on an MSN, and the biller pulls the matching ERA to explain it.

Related termsRemittance Advice (ERA)Explanation of Benefits (EOB)MedicarePatient Statement

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Also called CMS telehealth list; approved telehealth codes; Medicare telehealth eligible codes

Definition

The Medicare telehealth services list is the list of codes CMS allows to be billed when furnished by telehealth. Codes on the list can be billed with the proper modifier and place of service.

Why it matters

A code that is not on the list is not payable as telehealth by Medicare. The list and the rules around it have changed often, so confirm it before billing.

Illustrative example

A biller checks that a psychotherapy code is on the current list before scheduling a telehealth visit for a Medicare patient.

Related termsTelehealthTelehealth FlexibilitiesTelehealth Modifier 95In-Person Requirement (Medicare Mental Health)

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Medicare Learning Network (MLN)checked 10/9/26

CategoriesTelehealth TermsMedicare & Medicaid Terms

Also called one calendar year rule; Medicare filing deadline

Definition

The Medicare rule that generally requires claims to be filed within one calendar year after the date of service, with limited exceptions.

Why it matters

Late Medicare claims are generally denied.

Illustrative example

A claim for a March service must be received within a year.

Related termsTimely FilingMedicare Administrative Contractor (MAC)

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid TermsClaims Processing

Also called pharmacologic management; med management; medication management visit

Definition

Medication management is a psychiatric visit that focuses on monitoring and adjusting psychiatric medication. It is usually billed with an E/M code, sometimes with a psychotherapy add-on.

Why it matters

Choose the E/M level by MDM or total time. Add a psychotherapy code only if psychotherapy was done and documented separately.

Illustrative example

A psychiatrist reviews response and side effects and bills 99214.

Related termsE/M CodeCPT 99214CPT 90833Psychiatrist

Reference sourceAmerican Psychiatric AssociationAmerican Medical Association (AMA)checked 10/9/26

CategoriesBehavioral Health Specific TermsClaims Processing

Also called MAT; medications for opioid use disorder; MOUD

Definition

Treatment for substance use disorders that combines FDA-approved medication with counseling and behavioral therapy.

Why it matters

Has specific coding, coverage, and Medicaid rules.

Illustrative example

A prescriber bills an E/M and counseling for MAT.

Related termsSubstance Use Disorder TreatmentOpioid Treatment Program (OTP)

Reference sourceSAMHSAchecked 10/9/26

CategoriesBehavioral Health Specific TermsMedicare & Medicaid Terms

Also called Medicare supplement; Medicare Supplement Insurance

Definition

Private insurance that helps pay Medicare cost sharing for Original Medicare beneficiaries.

Why it matters

Often works as secondary coverage with automatic crossover.

Illustrative example

A Medigap plan pays the Part B coinsurance after Medicare pays.

Related termsCrossover ClaimSecondary Insurance

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid TermsEligibility & Benefits

Also called MedTrainer credentialing

Definition

A vendor offering credentialing, compliance, and training software. Naming a vendor here is not an endorsement or partnership.

Why it matters

Shows how credentialing and compliance tasks can be combined in one system.

Illustrative example

A clinic tracks license and training expirations in one platform.

Related termsCredentialing SoftwareCompliance Program

Reference sourceMedTrainerchecked 10/9/26

CategoriesCredentialing & EnrollmentEHR & Healthcare Technology Terms

Also called subscriber ID; insurance ID; policy number

Definition

The identifier the payer assigns to a covered member, often printed on the insurance card.

Why it matters

A wrong ID or missing prefix is a top cause of eligibility rejections.

Illustrative example

A card shows a three-letter prefix that must be included on the claim.

Related termsGroup NumberPayer IDEligibility Verification

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesEligibility & BenefitsProvider Data Management Terms

Also called MHC Medicare; LPC Medicare enrollment; Medicare mental health counselor

Definition

For Medicare, a mental health counselor generally needs a master's or doctoral degree and at least two years or 3,000 hours of post-master's clinical supervised experience, plus state licensure or certification. CMS lists mental health counselors among the practitioners who can bill Medicare for mental health services.

Why it matters

Counselors with titles such as LPC, LCPC, or LMHC may enroll if they meet the definition. State titles differ, so check requirements against the definition, not the title.

Illustrative example

An LPC confirms the degree, hours, and license and enrolls in Medicare as a mental health counselor.

Related termsLicensed Professional Counselor (LPC)Marriage and Family Therapist (Medicare)Clinical Social Worker (Medicare)Medicare Enrollment (PECOS)

Reference sourceCMS Medicare Learning Network (MLN)CMS (Centers for Medicare & Medicaid Services)American Counseling Associationchecked 10/9/26

CategoriesMedicare & Medicaid TermsCredentialing & Enrollment

Also called Mental Health Parity and Addiction Equity Act; parity law; MHPAEA

Definition

A federal law requiring most group health plans that cover mental health or substance use disorder benefits to apply financial requirements and treatment limits no more restrictive than those for medical and surgical benefits.

Why it matters

It is the legal basis for many appeals about visit limits, prior authorization, and reimbursement gaps in behavioral health.

Illustrative example

A plan requires prior authorization for outpatient therapy but not for comparable medical visits; that comparison is analyzed under parity.

Related termsNon-Quantitative Treatment Limitation (NQTL)Visit LimitParity ComplaintGuide: Mental health parity

Reference sourceU.S. Department of Labor, EBSACMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesAudits & ComplianceBehavioral Health Specific Terms

Also called MGMA

Definition

A professional association for medical practice administrators that publishes benchmarking data and practice management resources.

Why it matters

A source for practice operations benchmarks.

Illustrative example

A practice compares its metrics to MGMA benchmarks.

Related termsProductivity MetricsPayer Mix

Reference sourceMGMAchecked 10/9/26

CategoriesRevenue Cycle MetricsMedicare & Medicaid Terms

Also called NQTL comparative analysis; parity comparative analysis; MHPAEA analysis

Definition

A comparative analysis is a written analysis that a health plan or issuer must be able to provide to show that its non-quantitative treatment limits for mental health and substance use disorder benefits are comparable to and no more stringent than those for medical and surgical benefits.

Why it matters

Providers can ask a plan for it in a parity dispute, and regulators can request it. Prior authorization and network rules are common targets.

Illustrative example

A practice files a parity complaint about a plan's prior authorization rules and asks for the plan's analysis.

Related termsMental Health Parity (MHPAEA)Non-Quantitative Treatment Limitation (NQTL)Behavioral Health Parity ComplaintPrior AuthorizationGuide: Mental health parity

Reference sourceHHS (U.S. Department of Health and Human Services)SAMHSAchecked 10/9/26

CategoriesAudits & ComplianceEligibility & Benefits