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Billing Terms Glossary

Medicare and Medicaid Billing Terms: Definitions for Therapists and Psychiatrists

These Medicare and Medicaid billing terms are defined in plain English for therapists and psychiatrists. Medicare and Medicaid terms describe the government payers. Medicare rules are national. Medicaid rules are set by each state, so they vary and must never be merged.

In this section

91 terms defined
Written for psychotherapists and psychiatrists
Source organization linked on every entry

Back to the full billing terms glossary

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1115 Waiver

Medicaid (state-specific)

Also called: Section 1115 demonstration; Medicaid waiver

Definition: A federal approval that lets a state test different Medicaid approaches, such as new benefits or delivery models.
Why it matters: Explains state-specific programs and coverage differences.
Illustrative example: A state waiver adds community support services.

Verify: state-specific and time-limited.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Accountable Care Partnership Plan (ACPP)

Medicaid (state-specific)

Also called: MassHealth ACPP; ACO plan

Definition: A MassHealth managed care option in which an ACO partners with a health plan to manage care for members.
Why it matters: Behavioral health may be managed within the plan, changing contracts and authorization.
Illustrative example: A MassHealth member is enrolled in an ACPP.

Verify: confirm current MassHealth program structure.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsValue-Based Care Terminology Medicaid

Advance Beneficiary Notice (ABN)

Medicare

Also called: ABN; CMS-R-131; notice of non-coverage

Definition: A notice a provider gives a Medicare beneficiary before a service that may not be covered, so the patient can decide to receive it and accept financial responsibility.
Why it matters: Without a valid ABN, the provider may not be able to bill the patient for a denied service.
Illustrative example: A provider gives an ABN before a service that may be denied as not medically necessary.

Verify: confirm current form and use at cms.gov.

Related terms Medicare Patient Responsibility

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid TermsPatient Financial Responsibility Terms Medicare

Assignment (Medicare)

Medicare

Also called: accept assignment; Medicare assignment; participating provider assignment

Definition: In Medicare, accepting assignment means a provider agrees to accept the Medicare-approved amount as payment in full for a covered service. The patient is then responsible only for the deductible and coinsurance.
Why it matters: Providers that accept assignment on all claims are participating providers. Others are non-participating and may be subject to a limiting charge. Assignment on a Medicare claim is a different concept from a private-plan assignment of benefits.
Illustrative example: A participating clinical social worker accepts assignment and collects only the 20 percent coinsurance from the patient.

Verify: Confirm the current Medicare rules with your MAC.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsPayment & Reimbursement Medicare

Care Management Organization (CMO)

Medicaid (state-specific)

Also called: CMO; Georgia CMO

Definition: Georgia's term for the private plans that manage Medicaid and PeachCare for Kids benefits.
Why it matters: Each CMO has its own rules and portal.
Illustrative example: A therapist credentials with each CMO.

Time-sensitive: verify current CMOs.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

CHIP (Children's Health Insurance Program)

Medicaid (state-specific)

Also called: CHIP; SCHIP

Definition: A federal and state program that covers children in families with incomes too high for Medicaid but who cannot afford private insurance.
Why it matters: Rules vary by state, and some states run CHIP within Medicaid.
Illustrative example: A child covered by CHIP receives therapy under state rules.

Verify: state-specific.

Related terms Medicaid

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Clinical Psychologist (Medicare)

Medicare

Also called: CP Medicare; Medicare clinical psychologist; psychologist Medicare enrollment

Definition: For Medicare, a clinical psychologist is a psychologist licensed or certified at the independent practice level who directly provides diagnostic, assessment, preventive, and therapeutic services. CMS lists clinical psychologists among the practitioners who can bill Medicare for mental health services.
Why it matters: Enrollment and billing follow Medicare's provider type rules. A clinical psychologist can bill Medicare under their own NPI, and can reassign benefits to a group.
Illustrative example: A licensed psychologist enrolls in Medicare as a clinical psychologist and bills 90837 under their own NPI.

Verify: Definitions come from CMS booklet MLN1986542 (March 2026). Confirm current requirements.

Reference source CMS Medicare Learning Network (MLN) · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsCredentialing & Enrollment Medicare

CMS (Centers for Medicare & Medicaid Services)

Private payer

Also called: CMS

Definition: The federal agency within HHS that runs Medicare and works with states on Medicaid and CHIP.
Why it matters: CMS publishes the rules, fee schedules, and manuals that many payers follow.
Illustrative example: A practice checks the CMS website for the fee schedule.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms

Connecticut Behavioral Health Partnership

Medicaid (state-specific)

Also called: CT BHP; Connecticut Medicaid behavioral health

Definition: A Connecticut program that manages Medicaid behavioral health services through an administrative services organization.
Why it matters: Connecticut is a served state; behavioral health may be managed outside standard plans.
Illustrative example: A Connecticut provider enrolls with the program's administrator.

Verify: confirm current program and vendor.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Dual Eligible

General (all payers)

Also called: dually eligible; Medicare-Medicaid enrollee; dual-eligible beneficiary

Definition: A person enrolled in both Medicare and Medicaid.
Why it matters: Billing sequence, payment limits, and crossover rules are specific to dual eligibles.
Illustrative example: A patient with Medicare and Medicaid receives therapy; Medicare pays first.

Reference source CMS (Centers for Medicare & Medicaid Services) · Medicaid.gov

Categories Medicare & Medicaid TermsEligibility & Benefits

Dual Eligible Special Needs Plan (D-SNP)

Medicare and Medicaid

Also called: D-SNP; dual special needs plan; Medicare Medicaid dual plan

Definition: A dual eligible special needs plan is a Medicare Advantage plan for people who qualify for both Medicare and Medicaid. It coordinates benefits for those members.
Why it matters: Billing can involve Medicare, the plan, and the state Medicaid program. Check who pays what, and how the plan handles cost sharing that Medicaid covers.
Illustrative example: A patient with both Medicare and Medicaid enrolls in a D-SNP, so the biller checks how the plan handles cost sharing before billing.

Verify: Rules vary by plan and state.

Reference source CMS (Centers for Medicare & Medicaid Services) · Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms MedicareMedicaid

EPSDT

Medicaid (state-specific)

Also called: Early and Periodic Screening, Diagnostic and Treatment

Definition: The Medicaid benefit for people under 21 that requires coverage of medically necessary services, including many behavioral health services.
Why it matters: Affects coverage and authorization arguments for children's services.
Illustrative example: A Medicaid plan reviews a child's request under EPSDT standards.

Related terms Medicaid Medical Necessity

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Federal Medical Assistance Percentage (FMAP)

Medicaid (state-specific)

Also called: FMAP; federal Medicaid match; federal share of Medicaid

Definition: The federal medical assistance percentage is the share of a state's Medicaid spending that the federal government pays. It differs by state and is updated each year.
Why it matters: It explains why federal changes can affect state Medicaid budgets and rates. Providers seldom bill it, but it drives policy.
Illustrative example: A state announces a rate change and points to changes in the federal match.

Time-sensitive: Updated annually. Confirm the current rate at Medicaid.gov.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Federally Qualified Health Center (FQHC)

Medicare and Medicaid

Also called: FQHC; community health center billing

Definition: A federally qualified health center is a community-based health care provider that meets federal requirements and receives certain federal support. Medicare and Medicaid pay FQHCs under special payment methods rather than the standard fee schedule.
Why it matters: Behavioral health services at an FQHC follow FQHC billing rules, which differ from an independent practice's rules. Confirm the coding and payment rules before you bill.
Illustrative example: A therapist employed by an FQHC bills under the clinic's rules, not the standard professional claim rules.

Verify: Payment and coding rules are specific to FQHCs. Confirm with CMS and the state.

Reference source CMS (Centers for Medicare & Medicaid Services) · HRSA

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms MedicareMedicaid

Florida Statewide Medicaid Managed Care (SMMC)

Medicaid (state-specific)

Also called: SMMC; Florida Medicaid managed care

Definition: Florida's Medicaid managed care program delivered through contracted plans.
Why it matters: Florida is a served state; plans set their own rules.
Illustrative example: A Florida provider contracts with SMMC plans.

Verify: confirm at the state Medicaid site.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

Geographic Practice Cost Index (GPCI)

Medicare

Also called: GPCI; Medicare locality adjustment; geographic adjustment

Definition: A geographic practice cost index is a Medicare adjustment that changes payment to reflect differences in the cost of work, practice expense, and malpractice insurance across localities.
Why it matters: It is one reason the same code pays different Medicare amounts in different places. It works with relative value units and the conversion factor.
Illustrative example: Two practices bill the same code, and Medicare pays them different amounts because their localities have different GPCIs.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsPayment & Reimbursement Medicare

Georgia Families

Medicaid (state-specific)

Also called: Georgia Medicaid managed care; Georgia CMO

Definition: Georgia's Medicaid managed care program, delivered by care management organizations (CMOs).
Why it matters: Georgia is a served state; the CMO landscape is a known moving target.
Illustrative example: A Georgia provider contracts with each CMO.

Time-sensitive: CMO transition; verify with Georgia Medicaid.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

Georgia Pathways

Medicaid (state-specific)

Also called: Pathways to Coverage

Definition: A Georgia Medicaid coverage program with work and activity requirements, operating under a state waiver.
Why it matters: The program has a scheduled expiration that is a known moving target.
Illustrative example: A patient's Pathways coverage status is checked before service.

Time-sensitive: waiver expiry and work-requirement dates; verify with Georgia Medicaid.

Related terms Medicaid 1115 Waiver

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

H0031

General (all payers)

Also called: H0031 code

Definition: A HCPCS code for a mental health assessment by a non-physician, used by some state Medicaid programs and payers.
Why it matters: Unverified for in-home use; state and payer policy decides coverage.
Illustrative example: A state lists H0031 for a mental health assessment.

Verify: keep flagged until confirmed against the specific state manual.

Related terms Medicaid HCPCS Code H2015

Reference source CMS HCPCS

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms

H2015

General (all payers)

Also called: H2015 code

Definition: A HCPCS code for comprehensive community support services, per 15 minutes, used by some state programs.
Why it matters: Unverified for in-home use; state policy decides coverage.
Illustrative example: A state lists H2015 with 15-minute units.

Verify: keep flagged until confirmed against the specific state manual.

Related terms Medicaid HCPCS Code H2017

Reference source CMS HCPCS

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms

H2017

General (all payers)

Also called: H2017 code

Definition: A HCPCS code for psychosocial rehabilitation services, per 15 minutes, used by some state programs.
Why it matters: Unverified for in-home use; state policy decides coverage.
Illustrative example: A state lists H2017 with 15-minute units.

Verify: keep flagged until confirmed against the specific state manual.

Related terms Medicaid HCPCS Code H2015

Reference source CMS HCPCS

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms

Health First Colorado

Medicaid (state-specific)

Also called: Colorado Medicaid

Definition: The name of Colorado's Medicaid program.
Why it matters: Colorado is a served state; Medicaid rules there are separate from other states.
Illustrative example: A Colorado provider enrolls with Health First Colorado.

Verify: confirm at the state Medicaid site.

Reference source Medicaid.gov

Categories Medicare & Medicaid Terms Medicaid

HHS (Department of Health and Human Services)

Private payer

Also called: HHS

Definition: The federal department that oversees CMS, OIG, OCR, HRSA, SAMHSA, and other health agencies.
Why it matters: Parent agency for many rules referenced in billing.
Illustrative example: A rule is issued by HHS.

Reference source HHS (U.S. Department of Health and Human Services)

Categories Medicare & Medicaid TermsAudits & Compliance

Home and Community-Based Services (HCBS)

Medicaid (state-specific)

Also called: HCBS; 1915(c) waiver

Definition: Medicaid services delivered in the home or community instead of an institution, authorized through waivers or state plan options.
Why it matters: Many in-home and community behavioral health codes fall here, with strict documentation.
Illustrative example: A state HCBS program covers community supports.

Verify: state-specific.

Related terms 1115 Waiver In-Home Therapy Medicaid

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

HRSA

Medicaid (state-specific)

Also called: Health Resources and Services Administration

Definition: An HHS agency that supports health care access programs, including community health centers and workforce programs.
Why it matters: Relevant to safety-net providers and workforce funding.
Illustrative example: A health center reports to HRSA.

Reference source HRSA

Categories Medicare & Medicaid TermsQuality & Risk Adjustment Terms Medicaid

Illinois HealthChoice

Medicaid (state-specific)

Also called: HealthChoice Illinois; HCI; Illinois Medicaid managed care

Definition: HealthChoice Illinois (HCI) is the name of Illinois' Medicaid managed care program, run by the Illinois Department of Healthcare and Family Services (HFS) through contracted managed care plans.
Why it matters: Illinois is a served state; its plans, rules, and codes are separate from other states.
Illustrative example: An Illinois provider checks the HFS site for the current plans before contracting or billing.

Time-sensitive: HFS has announced new managed care contract awards in 2026; confirm the current plan list and start dates at hfs.illinois.gov before publishing any plan-level detail.

Reference source Illinois Department of Healthcare and Family Services (HFS)

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

Indian Health Service (IHS)

Medicaid (state-specific)

Also called: IHS; tribal health programs

Definition: A federal agency that provides health services to American Indian and Alaska Native people, with its own billing and referral rules.
Why it matters: Has special payer status rules and purchased/referred care processes.
Illustrative example: A provider bills IHS through a purchased/referred care authorization.

Verify: confirm rules at ihs.gov.

Related terms Medicaid Prior Authorization

Reference source Indian Health Service

Categories Medicare & Medicaid Terms Medicaid

Institutions for Mental Diseases (IMD) Exclusion

Medicaid (state-specific)

Also called: IMD exclusion; Medicaid IMD rule; IMD waiver

Definition: The IMD exclusion is a Medicaid rule that generally bars federal Medicaid payment for services for adults age 21 to 64 in an institution for mental diseases, which is a facility of more than 16 beds primarily engaged in treating mental illness or substance use disorders. States can seek waivers and other exceptions.
Why it matters: It affects coverage for residential and inpatient behavioral health care in Medicaid. Coverage and exceptions vary by state.
Illustrative example: A state uses a waiver to pay for short-term residential treatment despite the IMD rule.

Verify: Confirm the current rule and any state waiver.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Limiting Charge

Medicare

Also called: Medicare limiting charge; 115 percent rule

Definition: The limiting charge is the most a non-participating Medicare provider can bill a patient for a covered service that the provider does not accept assignment for. It is set as a percentage above the Medicare fee schedule amount.
Why it matters: It applies only to non-participating providers and only to certain provider types. Check whether it applies to your license type, and do not balance bill beyond it.
Illustrative example: A non-participating provider checks the limiting charge before billing a patient the difference above Medicare's approved amount.

Verify: Applicability and percentage depend on provider type. Confirm with CMS or your MAC.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsPayment & Reimbursement Medicare

Local Coverage Article (LCA)

Medicare

Also called: LCA; billing and coding article; Medicare contractor article

Definition: A local coverage article is a Medicare contractor document that gives billing and coding guidance that goes with a local coverage determination. Many carry an identifier that starts with the letter A, such as A57480.
Why it matters: Articles tell you which codes, modifiers, and diagnoses a Medicare contractor expects. They apply only in that contractor's jurisdiction.
Illustrative example: A biller reads the contractor's article to see how the MAC wants psychotherapy start and stop times documented.

Verify: Articles apply only to their own Medicare region.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Coverage Database, Article A57480 (WPS)

Categories Medicare & Medicaid TermsClaims Processing Medicare

Local Coverage Determination (LCD)

Medicare

Also called: LCD; local coverage article; LCA

Definition: A decision by a MAC about whether a service is covered in its jurisdiction, often with billing and documentation articles.
Why it matters: Rules differ by MAC jurisdiction.
Illustrative example: A MAC's article lists required documentation for psychotherapy.

Verify: apply only within the MAC's jurisdiction.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

MAC Jurisdiction

Medicare

Also called: Medicare jurisdiction; MAC region; Part B MAC jurisdiction

Definition: A MAC jurisdiction is the geographic area served by one Medicare Administrative Contractor. Each MAC processes claims and issues local rules for the providers in its area.
Why it matters: Which MAC you bill, and its local coverage rules, depend on where you practice. If you bill in more than one state, you may deal with more than one MAC.
Illustrative example: A practice in two states finds that each state is under a different MAC with different local articles.

Verify: Confirm your jurisdiction on CMS.gov.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsCredentialing & Enrollment Medicare

Marriage and Family Therapist (Medicare)

Medicare

Also called: MFT Medicare; LMFT Medicare enrollment; Medicare marriage and family therapist

Definition: For Medicare, a marriage and family therapist 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 MFTs among the practitioners who can bill Medicare for mental health services.
Why it matters: MFTs became eligible to enroll in Medicare as a provider type. Check current enrollment requirements and the services covered before billing.
Illustrative example: An LMFT confirms the degree, hours, and license and enrolls in Medicare as an MFT.

Verify: Definition from CMS booklet MLN1986542 (March 2026). Confirm current requirements.

Reference source CMS Medicare Learning Network (MLN) · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsCredentialing & Enrollment Medicare

MassHealth

Medicaid (state-specific)

Also called: Massachusetts Medicaid

Definition: The name of Massachusetts' Medicaid and CHIP program, which includes managed care options and behavioral health arrangements.
Why it matters: Massachusetts is a served state; MassHealth rules are separate from other states.
Illustrative example: A Massachusetts provider enrolls with MassHealth and contracts with plans.

Time-sensitive: behavioral health arrangements have been changing; verify with MassHealth.

Reference source Medicaid.gov

Categories Medicare & Medicaid Terms Medicaid

Medicaid

Medicaid (state-specific)

Also called: state Medicaid program; Medicaid billing

Definition: A joint federal and state program that provides health coverage to eligible low-income people, with rules that vary by state.
Why it matters: Medicaid is state-specific: covered services, codes, rates, and managed care plans differ.
Illustrative example: A state Medicaid program covers home-based therapy that another state does not.

Verify: never merge two states.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Medicaid Carve-Out

Medicaid (state-specific)

Also called: behavioral health carve-out (Medicaid); carved-out benefits

Definition: An arrangement where a state delivers certain benefits, often behavioral health, outside the main managed care plans, through a separate entity or fee-for-service.
Why it matters: Claims may go to a different payer than the member's medical plan.
Illustrative example: A member's physical health is in one MCO but behavioral health is handled by a separate entity.

Verify: state-specific.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Medicaid Expansion

Medicaid (state-specific)

Also called: expansion adult group; Medicaid expansion states; ACA Medicaid expansion

Definition: Medicaid expansion is the option under the Affordable Care Act for states to cover adults with incomes up to a set share of the federal poverty level. States decide whether to adopt it.
Why it matters: It changes who is covered in a state and can shape the payer mix of a behavioral health practice. Confirm whether your state expanded Medicaid.
Illustrative example: A practice serving both an expansion state and a non-expansion state sees different Medicaid eligibility patterns.

Time-sensitive: State decisions and federal law have changed. Confirm each state's current status.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

Medicaid HCPCS Code

General (all payers)

Also called: H-code; T-code; Medicaid behavioral health code

Definition: A HCPCS Level II code that a state Medicaid program uses for behavioral health services, such as community support or psychosocial rehabilitation. Definitions and rates vary by state.
Why it matters: Codes and their meaning are state-defined and must be checked in the state manual.
Illustrative example: A state's Medicaid manual lists an H-code and units.

Verify: state-specific; never merge two states.

Reference source Medicaid.gov · CMS HCPCS

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms

Medicaid Health Home

Medicaid (state-specific)

Also called: health home; Section 1945 health home; Medicaid health home program

Definition: A Medicaid health home is a state plan option under which a state can pay for coordinated care for people with certain chronic conditions, which can include serious mental illness and substance use disorders.
Why it matters: States design their own programs, so eligibility, providers, and payment differ. Providers may need to enroll separately.
Illustrative example: A state's health home program pays a clinic for care coordination for enrollees with serious mental illness.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Medicaid Managed Care Organization (MCO)

Private payer

Also called: MCO; Medicaid managed care plan; managed Medicaid

Definition: A private health plan that contracts with a state to deliver Medicaid benefits to enrolled members for a capitated payment.
Why it matters: Providers must contract with each MCO separately, and each has its own portal, authorization, and rules.
Illustrative example: A therapist is enrolled with the state and separately credentialed with three MCOs.

Verify: state-specific and changes often.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms

Medicaid Redetermination

Medicaid (state-specific)

Also called: Medicaid renewal; eligibility redetermination; Medicaid unwinding

Definition: A Medicaid redetermination, also called a renewal, is a state review to decide whether a person still qualifies for Medicaid. States must do it regularly.
Why it matters: Patients can lose coverage after a renewal, so verify eligibility before each visit and watch for retroactive changes.
Illustrative example: A patient's Medicaid ends after a renewal, and the biller finds out during an eligibility check.

Time-sensitive: State renewal processes and timing change. Confirm with the state.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

Medicaid Spend-Down

Medicaid (state-specific)

Also called: spend down; share of cost

Definition: A Medicaid feature in some states where a person with income above a limit becomes eligible after incurring medical expenses equal to the excess.
Why it matters: Eligibility can change month by month.
Illustrative example: A patient meets a spend-down and is eligible for the rest of the month.

Verify: state-specific.

Related terms Medicaid Retroactive Eligibility

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

Medicaid State Plan

Medicaid (state-specific)

Also called: state plan; Medicaid state plan; approved state plan

Definition: A Medicaid state plan is the agreement between a state and the federal government that describes how the state runs its Medicaid program, including who is eligible and which services are covered.
Why it matters: It explains why Medicaid differs from state to state. Covered behavioral health services, provider types, and rates come from the plan and from state rules.
Illustrative example: A practice reads its state's Medicaid plan and manual to see which provider types can bill therapy codes.

Verify: State-specific. Confirm with the state Medicaid agency.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Medicaid Work Requirements

Medicaid (state-specific)

Also called: community engagement requirements

Definition: Rules some states apply that require certain adults to work or participate in activities to keep Medicaid, subject to federal and state law.
Why it matters: Can change eligibility and cause coverage loss.
Illustrative example: A patient's coverage ends after missing requirements.

Time-sensitive: work-requirement deadlines; verify.

Related terms Medicaid Coverage Termination Date

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

Medicare

Also called: Original Medicare; Medicare Part A and B; federal health insurance for older adults

Definition: The federal health insurance program for people 65 and older and some younger people with disabilities. Part A covers hospital care, Part B covers outpatient care including most mental health services, and Part D covers drugs.
Why it matters: Outpatient psychotherapy and psychiatry for Medicare patients bill under Part B.
Illustrative example: A clinical social worker bills Medicare Part B for psychotherapy.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid Terms Medicare

Medicare Administrative Contractor (MAC)

Medicare

Also called: MAC; Medicare contractor; Part B MAC

Definition: A private company that processes Medicare fee-for-service claims and handles enrollment and provider education for a geographic jurisdiction.
Why it matters: Local coverage rules come from the MAC for the provider's jurisdiction.
Illustrative example: A practice checks its MAC's local coverage article for psychotherapy.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid Terms Medicare

Medicare Advantage

Medicare

Also called: MA; Medicare Part C; Medicare managed care

Definition: Private plans that contract with Medicare to provide Part A and B benefits, often with networks, prior authorization, and different billing rules from Original Medicare.
Why it matters: Claims go to the private plan, not the MAC, and network status is key.
Illustrative example: A patient's card shows a Medicare Advantage plan, so the claim goes to that plan.

Verify: plan rules vary; confirm with each plan.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid Terms Medicare

Medicare Beneficiary Identifier (MBI)

Medicare

Also called: MBI; Medicare number

Definition: The identifier that replaced the Social Security-based number on Medicare cards.
Why it matters: Claims need the MBI.
Illustrative example: A card shows an 11-character MBI.

Related terms Medicare Member ID

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicare

Medicare Benefit Policy Manual

Medicare

Also called: Benefit Policy Manual; Chapter 15 Covered Medical and Other Health Services; CMS IOM 100-02

Definition: The Medicare Benefit Policy Manual is a CMS manual that explains what Medicare covers. Chapter 15 covers medical and other health services, including rules that relate to incident-to services and other coverage details.
Why it matters: Billers and compliance staff use it to check whether Medicare covers a service and under what conditions. It carries more weight than a blog or a payer summary.
Illustrative example: A compliance officer checks Chapter 15 before allowing incident-to billing for a supervised clinician.

Verify: Confirm the chapter and section on CMS.gov.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsAudits & Compliance Medicare

Medicare Claims Processing Manual

Medicare

Also called: Claims Processing Manual; Pub. 100-04

Definition: The CMS manual that gives detailed billing and claims processing instructions for Medicare contractors and providers.
Why it matters: A primary source for Medicare billing questions.
Illustrative example: A biller cites Chapter 1 for filing rules.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

Medicare Coverage Database (MCD)

Medicare

Also called: MCD; CMS coverage database; NCD LCD article search

Definition: The Medicare Coverage Database is CMS's searchable database of national coverage determinations, local coverage determinations, and local coverage articles.
Why it matters: It is the place to check a Medicare contractor's coverage and billing rules for a code. Articles such as A57480 in the database are cited throughout this glossary.
Illustrative example: A biller searches the MCD for the LCD and article that apply to psychotherapy in their MAC's region.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsAudits & Compliance Medicare

Medicare Opt-Out Affidavit

Medicare

Also called: opt-out affidavit; private contract

Definition: A written statement filed by an eligible practitioner to opt out of Medicare for a period and contract privately with beneficiaries.
Why it matters: Strict rules apply; errors risk payment problems.
Illustrative example: A practitioner files an affidavit and uses private contracts.

Verify: consult the MAC or counsel.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsCredentialing & Enrollment Medicare

Medicare Part A

Medicare

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.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

Medicare Part B

Medicare

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 terms Medicare Deductible Coinsurance

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid Terms Medicare

Medicare Part B Deductible and Coinsurance

Medicare

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.

Time-sensitive: The deductible amount changes each year. Confirm the current amount at CMS.gov.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid TermsPatient Financial Responsibility Terms Medicare

Medicare Part D

Medicare

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.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

Medicare Physician Fee Schedule (MPFS)

General (all payers)

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.

Verify: rates are updated annually; check the current CMS file.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Physician Fee Schedule

Categories Medicare & Medicaid TermsPayment & Reimbursement

Medicare Physician Fee Schedule Look-Up Tool

Medicare

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.

Time-sensitive: Rates change each calendar year. Confirm the current amount in the tool.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsPayment & Reimbursement Medicare

Medicare Savings Programs

Medicare and Medicaid

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.

Verify: Eligibility and billing rules vary by state. Confirm with the state Medicaid agency.

Reference source CMS (Centers for Medicare & Medicaid Services) · Medicaid.gov

Categories Medicare & Medicaid TermsEligibility & Benefits MedicareMedicaid

Medicare Secondary Payer (MSP)

General (all payers)

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.

Verify: rules depend on employer size and situation.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits

Medicare Summary Notice (MSN)

Medicare

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.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

Medicare Timely Filing

Medicare

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.

Verify: confirm exceptions in the CMS Claims Processing Manual.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsClaims Processing Medicare

Medigap

Medicare

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 terms Crossover Claim Secondary Insurance

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicare

Mental Health Counselor (Medicare)

Medicare

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.

Verify: Definition from CMS booklet MLN1986542 (March 2026). Confirm current requirements.

Reference source CMS Medicare Learning Network (MLN) · CMS (Centers for Medicare & Medicaid Services) · American Counseling Association

Categories Medicare & Medicaid TermsCredentialing & Enrollment Medicare

MLN (Medicare Learning Network)

Medicare

Also called: MLN; Medicare Learning Network

Definition: A CMS education program with fact sheets, booklets, and articles for providers on Medicare billing and policy.
Why it matters: A reliable source for Medicare rules and definitions.
Illustrative example: A practice reads an MLN booklet on mental health services.

Reference source CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid Terms Medicare

Modified Adjusted Gross Income (MAGI)

Medicaid (state-specific)

Also called: MAGI; Medicaid MAGI eligibility; MAGI-based Medicaid

Definition: Modified adjusted gross income is the income method that Medicaid and CHIP use to decide eligibility for many groups, such as children, parents, pregnant people, and adults in expansion states.
Why it matters: It explains how eligibility is figured for many adults and children. Household size and income rules matter, and states run their own programs.
Illustrative example: A family's Medicaid eligibility is checked using MAGI rules and the state's income limit.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

National Coverage Determination (NCD)

Medicare

Also called: NCD

Definition: A CMS decision about whether Medicare covers a service nationwide.
Why it matters: Applies across all MACs.
Illustrative example: An NCD sets nationwide coverage for a treatment.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

North Carolina Medicaid Managed Care

Medicaid (state-specific)

Also called: NC Medicaid; Standard Plans; Tailored Plans

Definition: North Carolina's Medicaid managed care program, which includes standard plans and specialized plans for people with significant behavioral health needs.
Why it matters: North Carolina is a served state; plan types affect where behavioral health claims go.
Illustrative example: A provider checks whether a member is in a standard or tailored plan before billing.

Time-sensitive: program structure has changed; verify with NC Medicaid.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

NY Medicaid Managed Care

Medicaid (state-specific)

Also called: MAP; HARP; New York Medicaid plans

Definition: New York's Medicaid managed care landscape, including specialty arrangements such as Health and Recovery Plans (HARPs) for people with behavioral health needs.
Why it matters: New York is a served state; MAP transitions are a known moving target.
Illustrative example: A New York provider checks whether a member is in a specialty plan before billing.

Time-sensitive: MAP transitions; verify with NY Medicaid.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

Payer of Last Resort

Medicaid (state-specific)

Also called: Medicaid payer of last resort

Definition: The rule that Medicaid generally pays only after other available coverage has paid.
Why it matters: Requires billing other insurance first and documenting the response.
Illustrative example: A Medicaid claim is denied until the primary insurance's response is attached.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

Prepaid Ambulatory Health Plan (PAHP)

Medicaid (state-specific)

Also called: PAHP

Definition: A type of managed care entity that provides ambulatory services under a state contract on a prepaid basis.
Why it matters: Some states use PAHPs for behavioral health.
Illustrative example: A PAHP manages outpatient behavioral health for a state.

Verify: state-specific.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Prepaid Inpatient Health Plan (PIHP)

Medicaid (state-specific)

Also called: PIHP

Definition: A type of managed care entity that provides inpatient and often other behavioral health services under a state contract on a prepaid basis.
Why it matters: Some states use PIHPs to manage Medicaid behavioral health.
Illustrative example: A state contracts with a PIHP for mental health services.

Verify: state-specific.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Presumptive Eligibility

Medicaid (state-specific)

Also called: Medicaid presumptive eligibility; PE; temporary Medicaid coverage

Definition: Presumptive eligibility lets certain qualified entities temporarily enroll a person in Medicaid while a full application is reviewed.
Why it matters: Coverage can start before the full decision, so check the effective date and what services are covered. It may end if no application follows.
Illustrative example: A patient shows a presumptive eligibility letter, so the biller verifies the coverage dates before billing.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsEligibility & Benefits Medicaid

Private Contract

Medicare

Also called: Medicare private contract

Definition: A written agreement between a beneficiary and an opted-out practitioner in which the patient agrees to pay the practitioner directly and no Medicare payment is sought.
Why it matters: Must meet specific content rules.
Illustrative example: A patient signs a private contract with an opted-out psychiatrist.

Verify: consult the MAC or counsel.

Related terms Opt-Out (Medicare)Medicare

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicare

Qualified Medicare Beneficiary (QMB)

General (all payers)

Also called: QMB; QMB billing rules

Definition: A Medicaid program category in which the state pays Medicare cost sharing for eligible people. Providers generally may not bill QMB enrollees for Medicare cost sharing.
Why it matters: Billing a QMB patient for Medicare cost sharing can violate federal rules.
Illustrative example: A QMB patient's copay is sent to the state Medicaid program, not to the patient.

Verify: confirm current CMS guidance.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Medicare Learning Network (MLN)

Categories Medicare & Medicaid TermsPatient Financial Responsibility Terms

Reasonable and Necessary

Medicare

Also called: Medicare reasonable and necessary standard; Section 1862(a)(1)(A); medically reasonable and necessary

Definition: Reasonable and necessary is Medicare's basic coverage standard. Medicare generally pays only for services that are reasonable and necessary for the diagnosis or treatment of illness or injury.
Why it matters: It is the Medicare form of medical necessity. Notes should show why the service was needed, not just that it happened.
Illustrative example: A note describes the patient's symptoms, the intervention, and the goal, which supports the reasonable and necessary standard.

Verify: Confirm the language of the statute and local rules.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsAudits & Compliance Medicare

Regional Accountable Entity (RAE)

Medicaid (state-specific)

Also called: Colorado RAE; Accountable Care Collaborative

Definition: A Colorado Health First (Medicaid) entity that manages regional care coordination and behavioral health capitation for members in a region.
Why it matters: Colorado Medicaid behavioral health billing and contracts run through the RAE for the member's region.
Illustrative example: A Colorado therapist contracts with the RAE for the region where members live.

Time-sensitive: the RAE map and contracts change; confirm with Health First Colorado.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

Rural Health Clinic (RHC)

Medicare and Medicaid

Also called: RHC; rural health clinic billing

Definition: A rural health clinic is a clinic in a rural, underserved area that meets Medicare requirements and receives a special payment rate rather than the standard fee schedule.
Why it matters: Behavioral health services in an RHC follow RHC billing rules. Confirm the coding, provider types, and payment rules before you bill.
Illustrative example: A practice in a rural clinic bills a visit under RHC rules instead of the physician fee schedule.

Verify: Rules are specific to RHCs. Confirm with CMS and the state.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms MedicareMedicaid

SAMHSA

Medicaid (state-specific)

Also called: Substance Abuse and Mental Health Services Administration

Definition: An HHS agency that leads federal efforts on behavioral health, including grants, standards, and confidentiality rules for substance use records.
Why it matters: Source for behavioral health program standards and guidance.
Illustrative example: A program follows SAMHSA guidance on Part 2.

Reference source SAMHSA

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms Medicaid

Section 1915(b) Waiver

Medicaid (state-specific)

Also called: 1915(b); managed care waiver

Definition: A Section 1915(b) waiver is a Medicaid waiver that lets a state require enrollment in managed care or limit choice of providers.
Why it matters: Some states run behavioral health through a 1915(b) waiver, which can create a separate behavioral health carve-out network. Check how your state does it.
Illustrative example: A state moves its behavioral health benefit to a separate managed care entity under a 1915(b) waiver.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Section 1915(c) Waiver

Medicaid (state-specific)

Also called: 1915(c); HCBS waiver; home and community-based services waiver

Definition: A Section 1915(c) waiver is a Medicaid waiver that lets a state offer home and community-based services to people who would otherwise need institutional care.
Why it matters: Some behavioral health services, such as supports for people with serious mental illness or developmental needs, are offered through waivers. Eligibility and services vary by state and by waiver.
Illustrative example: A state offers community-based supports through a 1915(c) waiver, and a provider enrolls under that waiver.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Section 1915(i) State Plan HCBS

Medicaid (state-specific)

Also called: 1915(i); state plan home and community-based services

Definition: A Section 1915(i) benefit lets a state offer home and community-based services through its Medicaid state plan instead of through a waiver.
Why it matters: Some states use it for behavioral health supports. Requirements and the services offered differ by state.
Illustrative example: A state offers mental health rehabilitation supports under a 1915(i) state plan option.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

Special Needs Plan (SNP)

Medicare

Also called: SNP; Medicare Advantage special needs plan

Definition: A special needs plan is a type of Medicare Advantage plan designed for a specific group of people, such as those who are eligible for both Medicare and Medicaid or who have certain chronic conditions.
Why it matters: These plans may have their own networks, prior authorization rules, and care coordination. Check the specific plan's provider manual.
Illustrative example: A patient's Medicare Advantage card says the plan is a special needs plan, so the biller checks its network and authorization rules.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicare

State Plan Amendment (SPA)

Medicaid (state-specific)

Also called: SPA; Medicaid state plan amendment

Definition: A state plan amendment is a request a state sends to CMS to change its Medicaid state plan, such as adding a service or changing a payment method.
Why it matters: SPAs explain when a new Medicaid benefit or rate begins. Watch state announcements for behavioral health changes.
Illustrative example: A state adds coverage for a new peer support service through a state plan amendment.

Verify: State-specific.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid Terms Medicaid

T1017

General (all payers)

Also called: T1017 code

Definition: A HCPCS code for targeted case management, per 15 minutes, used by some state programs.
Why it matters: Unverified for in-home use; state policy decides coverage.
Illustrative example: A state lists T1017 for targeted case management.

Verify: keep flagged until confirmed against the specific state manual.

Related terms Medicaid HCPCS Code H2017

Reference source CMS HCPCS

Categories Medicare & Medicaid TermsBehavioral Health Specific Terms

TennCare

Medicaid (state-specific)

Also called: Tennessee Medicaid

Definition: The name of Tennessee's Medicaid program, which uses managed care organizations.
Why it matters: Tennessee is a served state; its plans and rules are separate from others.
Illustrative example: A Tennessee provider contracts with TennCare MCOs.

Verify: confirm at the state Medicaid site.

Reference source Medicaid.gov

Categories Medicare & Medicaid Terms Medicaid

Texas Medicaid STAR

Medicaid (state-specific)

Also called: STAR; STAR+PLUS; Texas Medicaid managed care

Definition: Texas Medicaid managed care programs, including STAR for most children and families and STAR+PLUS for adults with disabilities and older adults.
Why it matters: Texas is a served state; program names help identify the correct plan.
Illustrative example: A Texas provider checks the member's program before billing.

Verify: confirm at the Texas Health and Human Services site.

Reference source Medicaid.gov

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms Medicaid

Third-Party Liability (TPL)

Medicaid (state-specific)

Also called: TPL; Medicaid third party liability; Medicaid payer of last resort

Definition: Third-party liability means another source of coverage, such as a commercial plan, may be responsible for a Medicaid member's health care costs. Medicaid is generally the payer of last resort.
Why it matters: Bill the other coverage first, then Medicaid. Missing another plan on a Medicaid claim can cause a denial or a recovery.
Illustrative example: A Medicaid patient also has an employer plan, so the biller bills the employer plan first.

Verify: State-specific billing rules apply.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories Medicare & Medicaid TermsPayment & Reimbursement Medicaid

TRICARE

Private payer

Also called: military health system; TRICARE billing

Definition: The health care program for uniformed service members, retirees, and their families, administered through regional contractors.
Why it matters: Has its own network, authorization, and claim rules separate from Medicare and commercial plans.
Illustrative example: A therapist enrolls with the TRICARE contractor for the region.

Verify: contractors and regions change.

Reference source TRICARE

Categories Medicare & Medicaid TermsBCBS, UHC & Commercial Payer Terms TRICARE / VA

Veterans Affairs Community Care

Private payer

Also called: VA Community Care Network; CCN; VA community care

Definition: A program through which the Department of Veterans Affairs authorizes care from community providers for eligible veterans.
Why it matters: Requires VA authorization and has its own billing rules and networks.
Illustrative example: A community therapist provides care under a VA authorization.

Verify: confirm current administrators and rules at va.gov.

Related terms TRICARE Prior Authorization

Reference source U.S. Department of Veterans Affairs

Categories Medicare & Medicaid Terms TRICARE / VA

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