Abbreviation and Terminology
children's hospital of los Angeles
- Automated Eligibility Verification System-This system is used via the the telephone to verify patient's
eligibility with Medi-cal
- A document or number provided by a patient's PCP or their insurance review
agency which informs the specialist that they are aware that the patient
is being treated and approved has been granted to provide care.
An authorization never is a guarantee of payment.
- Birth date Rules
- Applies when recipient has two private insurances. The parent whose birth month falls first is considered the PHP, if on the same month and day then the corresponding year.
- Method of payment
- California children's services A State and County program providing medically necessary specialized care and rehabilitation to persons under 21 years of age with physically handicapping conditions as defined in Title 22, who meet medical, financial and residential eligibility requirements specified for CCS Program
- CCS Carve out
- This is applicable to patients who belong to Medi-cal Managed Care and have CCS Eligible Condition (and would be registered as CCS primary and Medi-cal secondary.
- Child Health & Disability Prevention Program Preventive well child screening program for eligible beneficiaries under 21 years of age provided in accordance with the specific provisions of Title 17.
- The specific amount a recipient/guarantor must pay prior to rendered medical services. Carrier determines this amount.
- Department of health service
- Electronic Data System Organization that processes claims for the Medi-cal program.
- Fee for Service
- individual who is responsible for paying the services provided to recipient/patient.
- Health Maintenance Organization An organization that ,through a coordinated system of health care, provides or assures the delivery of an agreed upon set of comprehensive health maintenance and treatment services for an enrolled group of persons through a predetermined periodic fixed prepayment.
- Individual that has the insurance benefits. This term is used interchangeably with subscriber.
- Independent Physician Association
- Length of Stay
- Medi-cal POS
- Point of Service This network allows providers access to recipient eligibility, share of cost clearance, and medi-reservations. This system can be access through AEVS or a POS device
- Medic-Cal Share of Cost
- Co-Pay or Deductible, See SOC
- Primary Care Physician A physician responsible for supervising, coordinating, and providing initial and primary care to patients; for initiating referrals for specialist care; and for maintaining the continuity of patient care
- Primary Health Plan
- Preferred Provider Organization
- Share of Cost Term used for Medi-cal recipients. Specific amount a recipient must pay for medical expenses before eligibility for certification for Medi-Cal benefits. (This must be collected on a monthly basis when medical care is rendered.
- Remittance Advice Detail Document providers receive from EDS with detail information with claims eligibility and/or denial.
- The practice of sending a patient to another practitioner for services or consultation which the referring provider is not prepared or prepared or qualified to provide
- Individual receiving medical care
- Individual who provides insurance benefits to recipient through employer eligibility, self obtained policy or a State agency provides the insurance coverage.