Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/412

Click to flip

412 Cards in this Set

  • Front
  • Back
372
CMS Waiver Report (formerly HCFA Waiver Report).
3650
LOC Assessment form used for the DBMD and CLASS programs
3652-A
The Client Assessment, Review, and Evaluation form used for the CBA, MDCP, and CWP waiver programs.
AA
Adaptive Aids.
AAA
Area Agencies on Aging.
AAMR
American Association on Mental Retardation.
AAPCC
Adjusted Average Per Capita Cost.
ABL
Adaptive Behavior Level.
Accessibility of Service
The relative opportunity for people in need to obtain relevant services.
ACS
Affiliated Computer Service.
ADA
American with Disability Act.
ADL
Activities of Daily Living.
AFC
Adult Foster Care. Services provided in a 24-hour living arrangement with supervision in an adult foster home for individuals who, because of physical, mental, or emotional limitations, are unable to continue independently functioning in their own homes.
Advocate
One who is available to the consumer for assistance or support when needed.
Agreement Assignee
The waiver program provider to which a waiver program provider agreement is transferred.
Agreement Assignor
The waiver program provider from which a waiver program provider agreement is transferred.
AIC
Area Information Center.
ALF
Assisted Living Facility. Residences that provide a “home with services” and that emphasize residents’ privacy and choice. Residents typically have private locking rooms (only shared by choice) and bathrooms. Personal care services are available on a 24-hour-a-day basis.
ANE
Abuse, Neglect, Exploitation.
AN1A
A Department of Family and Protective Services form used to complete a Client Abuse and Neglect Report.
APS
Adult Protective Services.
Applicant - Provider
A person or business that is seeking to obtain a waiver program provider agreement.
Applicant
An individual whose eligibility for waiver services is in the process of being determined. An individual becomes an applicant when he is next in line to fill a slot in the waiver program, a slot becomes available, and DADS has approved the filling of the slot. Further, DADS has notified the individual, and the individual has submitted the required application materials to DADS within a specified time frame.
Assignment of a waiver program provider agreement
The transfer of rights, interest, and obligations of the waiver program provider agreement from the program provider to another person.
Application Packet (provider)
The paper work received by a person representing an entity applying for certification to provide services for a state waiver program. The applicant receives one packet for each waiver program for which they want to provide services.
BBA
Balanced Budget Act.
BENDEX
Benefits Data Exchange. A matching of social security numbers to determine RSDI (Retirement, Survivors and Disability Income)? The BENDEX file is produced for the states by the SSA. The BENDEX is created from the Master Beneficiary Record (MBR). The primary purpose of the BENDEX is to assist the States in administering the Aid to Families with Dependent Children (AFDC) program and the Medical Assistance program.
B/FM
Billing/Fiscal Monitoring. A division of legacy TDMHMR Medicaid Administration Department.
BHO
Behavioral Health Organization.
Budget Number
A two-digit number indicating the budget to bill against. This item is needed for block grant services.
BuyIn
A program in which the state pays Supplemental Medical Insurance (SMI) premiums for eligible Medicaid recipients.
CARE
Client Assignment and Registration System. Legacy MH/MR mainframe system that provides demographic and other data about individuals served by the Department
CARE ID
A unique identifier across CARE applications.
CARE Form 3652
CARE Form 3652. An assessment form created by legacy Texas Department of Human Services in the 1980s that is used to determine medical necessity and nursing facility reimbursement and certain waiver cost caps. The CARE Form 3652 is TX specific.
CAS
Community Attendant Service. Formerly known as the Frail Elderly or 1929 (b), CAS is a non-technical, non-medical attendant care service for recipients of all ages whose chronic health problems impair their daily living.
Case Manager
A DADS employee who is responsible for case management activities. Activities include eligibility determination, participant registration, assessment and reassessment of participant's need, service plan development, and intercession on the participant's behalf.
CAM
Cost Accounting Methodology.
CANRS
Client Abuse Neglect Reporting System - The Department’s system that records abuse and neglect allegations. All state facilities and community centers are required to use CANRS.
CBA
Community Based Alternatives. A Medicaid waiver program that provides home and community-based services to aged and disabled adults as a cost-effective alternative to nursing facility care.
CCC
Community Care Contracting.
CCAD
Community Care for Aged and Disabled replaced by the term Community Services (CS); umbrella for all Title XX and some Medicaid programs
CCAT
Community Care Assessment Tool.
CCP
Comprehensive Care Program.
CCR
Community Contract Register.
CDS
Consumer Directed Services. A program that empowers consumers to make personal decisions related to the delivery of Personal Assistance Services and Respite Services within his or her current home and community-based program.
CFDA
Catalog of Federal Domestic Assistance.
CHIP
Children’s Health Insurance Program.
CI
Critical Incident. An event relating to a physical condition or medical crisis where chemical restraint, personal restraint or mechanical restraint was utilized or where medical errors or serious injury occurred. This event is inconsistent with routine practice.
Claim
A request for payment of services from a provider for a single individual that consists of one or more types of services performed for the individuals and may span multiple months but cannot span fiscal years.
CLASS
Community Living Assistance and Support Services. A Medicaid waiver program that provides community-based services as an alternative to Intermediate Care Facility/Mental Retardation (ICF/MR VIII) institutional care for people with developmental disabilities other than mental retardation.
CLO
Community Living Option.
CMPAS
Consumer Managed Personal Assistance Services. Financial intermediary services provided to eligible individuals who supervise or have someone who can supervise their attendant. Individuals are responsible for interviewing, selecting, training, supervising and releasing their attendants.
CMS
Centers for Medicare and Medicaid Services. The federal agency that administers Medicaid programs.
CMS
Claims Management System.
Complaint
Allegation of a rights violation, a statement of dissatisfaction concerning any aspect of the service delivery system, including but not limited to the denial, reduction, or termination of a service, the way in which a service is provided, or the provisions of a contract, rule, or statute.
Compliance Principles
Policies that are predetermined by legacy TDMHMR and agreed to by a waiver provider that require compliance.
Component Code
An alphanumerical assignment used to identify a specific program provider; e.g., Andrews Center’s component code is 190.
Consumer Choice
Provided when there is a range of service options to meet the diverse needs of consumers. The degree to which consumers have choice must go beyond the range of service choices and include opportunities for consumers to decide when and where services will be provided, and how and by whom tasks will be performed.
Community-Based Services
Services designed to help people remain independent and in their own homes; can include senior centers, transportation, delivered meals or congregate meals site, visiting nurses or home health aides, adult day care, and homemaker services.
CS
Community Services. The term replacing CCAD.
Consultation
Advising on accessibility and availability of services, including: the waiting list for services, other appropriate resources, and relevant rights, rules, statutes on service provision and eligibility.
Consumer / Client / Individual / Person
An individual who has been determined eligible to receive waiver services, has enrolled in s waiver program, and receives waiver services.
Contract
Used interchangeably with agreement. A formal agreement with the Department that specifies services to be provided.
Contract Manager
The formal, written agreement between DADS and a provider agency to provide services to DADS participants eligible under this chapter in exchange for reimbursement.
Contract Number
A unique number that identifies a provider agreement/contract. This number is not duplicated across WCA or programs (except ICF).
Corrective Actions
An activity intended to correct an action.
Corrective Action Plan
An agenda developed by a waiver program provider containing activities intended to correct an action found out of compliance during a review.
Cost Ceiling
The upper limit set for an Individual Plan of Care.
Cost Effective
The estimated average annualized cost of the applicant's individual service plan for waiver services must not exceed a ceiling based on the waiver formula calculation.
CPA
Comptroller of Public Accounts.
CPS
Child Protective Services.
Crisis Intervention
A situation where a client is in need of immediate intervention for safety or health concerns.
CSHB
Committee Substitute House Bill.
CSHCN
Children with Special Health Care Needs.
CSIL
Consolidate Interest List.
CSRP
Consumer Services and Rights Protection. A division of legacy TDMHMR whose function is to represent consumers and family members in the mediation and resolution of their concerns and complaints in relation to treatment, legal and basic rights and to assist persons in locating mental health and mental retardation services and other public and private resources.
CWP
Consolidated Waiver Program. A 1915(c) Medicaid waiver program that provides services to the aged, disabled, developmentally disabled, and persons with mental retardation as an alternative to institutional care in a nursing facility or intermediate facility for the mentally retarded (ICF-MR). Both children and adults are served. The program offers services to those individuals that qualify to achieve or maintain dignity, independence, individuality, privacy, choice, and decision-making ability. The program also offers services to prevent or reduce inappropriate institutional care by providing home-based care and other forms of less intensive care.
DADS
Department of Aging and Disability Services. The following services are regulated and provided by DADS: mental retardation services; state school programs; community care, nursing facility, & long-term care regulatory services; and aging services & programs.
DAHS
Day Activity and Health Services. Facilities providing daytime services to individuals residing in the community. Services are designated to address the individual’s physical, mental, medical, and social needs. Services include the provisions of nursing and personal care, physical rehabilitation, noon meal and snaks, transportation, social, educational, recreational, and activities.
DANSA
Dallas Area NorthSTAR Authority.
DARS
Department of Assistive and Rehabilitation Services.
DBMAT
Deaf Blind Multi-handicapped Association of Texas.
DB/MD
Deaf-Blind with Multiple Disabilities Program. A Medicaid waiver program that provides home and community-based services to people who are deaf and blind with multiple disabilities as a cost-effective alternative to Intermediate Care Facility the Mentally Retarded (ICF-MR/RC) institutional placement.
Determination
The settling of a question or case by an authoritative decision or pronouncement.
Developmental Disabilities
A severe and chronic disability manifested during the developmental period before the age of 22, which results in impaired intellectual functioning or deficiencies in essential skills.
DFPS
Department of Family and Protective Services. Previously DPRS; the State of Texas department charged with protecting children, adults who are elderly or have disabilities living at home or in state facilities, and licensing group day-care homes, day-care centers, and registered family homes.
Discretionary Sanction
A sanction exercised at the reviewer’s discretion based on reasons bearing on the entity's professional competence, professional performance, or financial integrity.
DME
Durable Medical Equipment.
DMR
Department of Mental Retardation.
DPMO
Departmental Program Management Office.
DRG
Diagnosis Related Group.
DSH or DISPRO
Disproportionate share.
DSHS
Department of State Health Services.
Due Diligence
The level of judgment, care, prudence, determination, and activity that a person would reasonably be expected to do under particular circumstances.
Dual Eligibles
Individuals who qualify for both Medicare benefits and Medicaid assistance. There are two types of dual eligibles: 1) those who receive full Medicaid benefits, and 2) those for whom Medicaid pays for all or part of the Medicare premiums, co-payments and deductibles.
DVC
Data Verification Criteria.
ECF
Extended Care Facility.
ECI
Early Childhood Intervention.
EMR
Employee Misconduct Registry.
Entitlement Program
The Medicaid entitlement acts as a "safety net" for eligible individuals in need. Medicaid spending is not limited to a fixed amount of funds nor are the benefits limited to a fixed number of beneficiaries. The Medicaid rolls often fluctuate in response to factors such as economic recessions and natural disasters. The Medicaid entitlement guarantees that eligible individuals have access to a minimum level of benefits regardless of the state in which they live.
EPSDT
Early Periodic Screening, Diagnosis and Treatment.
EOA
Equity of Access.
EQRP
External Quality Review Organization.
ERS
Emergency Response Services. Services provided through an electronic monitoring system and used by functionally impaired adults who live alone or who are socially isolated in the community.
EWS
Early Warning System.
Fair Hearing
A hearing before a fair hearing officer giving the complainant the chance to have a decision reviewed.
Family Based Alternative
A family setting in which the family provider or providers are specially trained to provide support and in-home care for children with disabilities or children who are medically fragile.
FC
Family Care.
FE
Frail Elderly.
FFP
Federal Financial Participation.
FFS
Fee for Service.
FFY
Federal Fiscal Year.
FGP
Foster Grandparents Program.
Finalized Claim
A claim that has completed processing through the Claims Management System and has a paid or denied status.
Financial Eligibility
Income eligibility rules for certain individuals under home and community-based waivers.
FMAP
Federal Medicaid Assistance Percentage.
FORM 2314
Consumer Satisfaction Interview.
FORM 3624
Termination, Reduction, or Denial of CLASS.
FORM 3650
Level of Care.
FORM 3652-A
Client Assessment, Review and Evaluation (Care).
FORM 6500
Individual Service Plan.
FORM 6501
Deaf-Blind Medicaid Interest List Form.
FPL
Federal Poverty Level.
FQHC
Federally Qualified Health Center.
FRC
Federal Records Center.
Frail Elderly
Previous name for Community Attendant Services (CAS).
FS
Food Stamps.
General Revenue (GR)
Monies that are collected by the state of Texas via taxes and other state-generated income.
GOBPP
Governor’s Office of Budget, Planning, and Policy.
Good Cause
A legally sufficient reason for a ruling or action.
HB
House Bill.
HCFA
Health Care Financing Administration (now CMS).
HCPCS
HCFA Common Procedural Coding System. A set of codes used by Medicare that describes services and procedures. HCPCS includes Current Procedural Terminology (CPT) codes for services not included in the normal CPT code list, such as durable medical equipment and ambulance service. While HCPCS is nationally defined, there is a provision for local use of certain codes.
HCS
Home and Community based Services. The Home and Community-Based Services Program operated by the department as authorized by CMS in accordance with §1915(c) of the Social Security Act. . There are also other federal, state and local dollars that fund home and community based services, including the Social Services Block Grant (SSBG), Older Americans Act (OAA), Education and Rehabilitation funds and State General funds.
HCS Case Manager
An employee of the program provider who is responsible for the overall coordination and monitoring of services provided to an individual enrolled in an HCS program.
HCSSA
Home and Community Support Services Agency.
HDM
Home-Delivered Meals.
HEDIS
Health Plan Employer Data and Information Set.
HHS
Health and Human Services.
HHSC
Health and Human Services Commission. The State of Texas department that has oversight responsibilities for designated health and human services agencies and administers certain health and human services programs including the Texas Medicaid Program, and Children's Health Insurance Program
HHSC Ombudsman
A process to investigate complaints and mediate fair settlement.
HICA
Health Information Counseling and Advocacy Program.
HIPAA
Health Insurance Portability and Accountability Act.Title I protects health insurance coverage for workers and their families when they change or lose their jobs. The Administrative Simplification provisions (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data.
HJR
House Joint Resolution.
HMO
Health Maintenance Organization.
HPS
Hospice. Medical, social, and support services for terminally ill individuals, with no known curative treatment options, who have a prognosis of less than six months to live.
HRO
House Research Organization.
HUB
Historically Underutilized Business.
IAC
Inter-Agency Contract.
ICAP
Inventory for Client and Agency Planning. The ICAP is used to assess adaptive and maladaptive behavior and gather additional information to determine the type and amount of special assistance that people with disabilities may need.
ICF/MR or ICFs/MR
Intermediate Care Facility for Persons with Mental Retardation. Institutional care and treatment for individuals with mental retardation with an onset date before 18 years of age.
ICN
Internal Control Number. A Claims Management System-assigned number to uniquely identify an accepted claim.
IDT
Interdisciplinary Team. A group of professionals, paraprofessionals and non-professionals who possess the knowledge, skill and expertise necessary to accurately identify the comprehensive array of the individual's needs and design appropriate services and specialized programs responsive to those needs; consisting of, at a minimum, the individual and LAR, HCS case manager, and a nurse.
IGT
Inter-Governmental Transfer.
IHFS
In Home Family Support.
IMD
Institution for Mental Disease.
Imminent Danger
Exposure or vulnerability to impending health or physical harm.
Individual
An individual determined by DADS as eligible for LTC or community services. The individual may also be referred to as a “consumer” or a “participant”. In the case of a nursing facility, the individual my be referred to as a “resident”.
IPA
Individual Practice Association.
IPC
Individual Plan of Care. A document that describes the type and amount of each service component to be provided to an individual and medical and other services and supports to be provided through non-waiver program resources.
IPP
Individual Program Plan. The IPP includes services (types, units, frequency, duration, and cost) a participant receives. It also identifies non-waiver services that the participant accesses in the community.
ISP
Individual Service Plan. A written plan describing the assessments, recommendations, deliberations, conclusions, justifications and outcomes regarding the specific services provided to the individual by the program provider.
IQF
Interactive Quality Forum.
IT
Information Technology. A division of DADS.
Informal Re-consideration
State review procedures made available in cases of non-renewal, denial, cancellation, or termination of the provider agreement for a HCS or TxHmL waiver program provider.
Intermittent Review Reason
A code that represents the reason an intermittent review was held. The values are: complaint, DFPS report, and other concerns.
JAD
Joint Application Development. A system development methodology that involves the client or end user in the design and development of an application, through a succession of collaborative workshops called JAD sessions.
LA
Local Authority.
LAR
Legally Authorized Representative. A person authorized by law to act on behalf of a person in a waiver program and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult.
LBB
Legislative Budget Board.
LBHA
Local Behavioral Health Authority.
Large ICF/MR
A non-state operated ICF/MR with a Medicaid certified capacity of 14 or more.
Level I Sanctions
A sanction that is imposed when available evidence indicates the contract is in non-compliance with 12-23 principles at the time of the exit conference. Discretionary Level I Sanctions can be imposed when available evidence indicates the contract is in non-compliance with fewer than 12 principles at the time of the exit conference, but the non-compliance is of a serious or pervasive nature. Requires an on-site follow-up review by Waiver Survey and Certification 30-45 days from the exit conference of the review where Level I Sanctions were imposed. If all items are not corrected at the time of the follow-up review, vendor hold is initiated, and a second on-site follow-up review is conducted by Waiver Survey and Certification 30-45 days from the initiation of vendor hold. If all items are not in compliance at the time of the second follow-up, de-certification of the contract is initiated by Waiver Survey and Certification.
Level II Sanctions
A sanction that is imposed when available evidence indicates the contract is in non-compliance with 24 or more principles at the time of the exit conference. Discretionary Level II Sanctions can be imposed when available evidence indicates the contract is in non-compliance with fewer than 24 principles at the time of the exit conference, but the non-compliance is of a serious or pervasive nature. Results in vendor hold. Requires an on-site follow-up review by Waiver Survey and Certification 30-45 days from the initiation of vendor hold. If all items are not in compliance at the time of the follow-up, de-certification of the contract is initiated by Waiver Survey and Certification.
Amount of assistance required by consumers which may determine their eligibility for programs and services. Levels include: protective, intermediate, and skilled.
LMHA
Local Mental Health Authority.
LOC
Level of Care. Texas Index for Level of Effort. Eleven-category case-mix system to determine nursing facility and certain waiver program reimbursement and cost-caps. Unique case-mix system developed in TX based on 1987 data and implemented on April 1, 1989. Current data do not reflect changes in practice patterns and resident characteristics over the past two decades. Data are derived from the CARE Form 3652. LOC is the criteria used to determine the extent of the consumer’s need for services and in the HCS and TxHmLwaivers is based on data submitted on the MR/RC Assessment.
LOI
Letter of Intent.
Local Case Number
An identifier assigned by the provider for a consumer for whom they provide services.
Location Code
A code that identifies where the consumer resides.
LON
Level of Need. Range of medical and/or social services designed to help people who have disabilities or chronic care needs. Services may be short or long term and may be provided in a person's home, in the community, or in residential facilities (e.g., nursing homes or assisted living facilities). In the TxHmL and HCS waivers LON is derived from the service level score obtained from the administration of the Inventory for Client and Agency Planning (ICAP) to the individual and from selected items on the MR/RC Assessment.
Level of Service
The level of effort necessary for a provider to provide service to an individual. The level of service is a factor in determining the payment rate for services to the individual. Level of service includes level of care, level of need, and priority status.
LTC
Long Term Care. Long-term care is provided to persons who require assistance with health care and/or activities of daily living because of ageing or `a chronic physical or cognitive disability.
LTC-R
Long Term Care-Regulatory.
LTCS
Long Term Care Services.
MAC
Medicaid Administration Claiming.
MAO
Medical Assistance Only - Provides medical coverage for individuals who are age 65 and over, blind or disabled, but do not receive monthly cash benefits under the Supplemental Security Income program.
MCAC
Medical Care Advisory Committee.
MCD
Medicaid/CHIP Division.
MCO
Managed Care Organization.
MDCP
Medically Dependent Children’s Program. A Medicaid waiver program that provides a variety of services to support families caring for children who are medically dependent, and to encourage deinstitutionalization of children in nursing facilities.
MDS
Minimum Data Set. A federally required functional assessment and care-planning document mandated by the Omnibus Budget Reconciliation Act of 1987 (OBRA 87). While created specifically as an assessment and care-planning tool, it has evolved into a reimbursement form. The foray into payment was the development of the Prospective Payment System (PPS) for Medicare skilled nursing facility residents. A number of states use this document to determine Medicaid nursing facility reimbursement through the RUGS methodology.
MDU
Multiple Disabilities Unit (State Hospitals).
Medicaid
A federal program, jointly funded by the states and the federal government, that reimburses hospitals and physicians for providing care to qualifying people who cannot finance their own medical expenses.
Medicaid Number
A unique identifier assigned to all Medicaid recipients.
Medicare Part A
The program that typically pays for your inpatient hospital expenses.
Medicare Part B
The program that typically covers your outpatient health care expenses including doctor fees.
Medicare Part C
Medicare Programs that provide for managed care plans; preferred provider organization (PPO) plans; private fee-for-service plans; or specialty plans.
Medicare Part D
The Medicare prescription drug coverage program.
Mental Retardation/Related Condition Assessment
A form used by the Department for LOC determination and LON assignment.
Mental Retardation
Significantly sub average general intellectual functioning that is concurrent with deficits in adaptive behavior and originates during the developmental period .
MFCU
Medicaid Fraud Control Unit (a division of OIG).
MH
Mental Health.
MHA
Mental Health Authority.
MHMR
Mental Health and Mental Retardation (Legacy state agency).
MIS
Management Information System.
MMIS
Medicaid Management Information System.
MN
Medical Necessity. A determination made on each individual seeking Medicaid long-term care support and services. The federal government requires that each state operationally define a level that is a pre-determined threshold to receive services/supports.
MPI
Medicaid Program Integrity (a division of OIG).
MOU
Memorandum of Understanding.
MR
Mental Retardation.
MRA
Mental Retardation Authority.
MR/DD
Mental Retardation/Development Disability.
MRLA
Mental Retardation Local Authority.
MSA
Metropolitan Statistical Area. Metropolitan areas organized around county boundaries.
MSIS
Medicaid Statistical Information System. Refers to standards set by Medicare/Medicaid for the transmission of electronic data.
MTP
Medical Transportation Program.
Multiple Disabilities
A person is considered to have multiple disabilities if, in addition to deafness and blindness, he or she has one or more disabilities that result in impairment to independent functioning. The person's adaptive behavior level must be rated 2 or greater. As a result, he or she must not be capable of living independently without substantial support.
NATCEP
Nurse Aide Registry and Nurse Aide Training and Competency Evaluation Program.
NCI
National Core Indicators. NCI produces a consumer survey used to identify and measure core indicators of performance of state developmental disabilities service systems.
NF
Nursing Facility. The nursing facility program provides nursing care and appropriate rehabilitative/restorative services to eligible Medicaid recipients.
NFA
Nursing Facility Administrator.
Non-waiver Services
Services that are not provided under waiver provisions of Section 1915 (c) of the Social Security Act.
NorthSTAR
Texas' managed care program for behavioral health services that was implemented in 1999 for Dallas and contiguous counties. NorthSTAR integrates Medicaid-funded and public, non-Medicaid funded mental health and chemical dependency services. The program includes state and federal Medicaid funds (through a 1915 (b) waiver), non-Medicaid state and federal funds, and some county funds. NorthSTAR behavioral health services are "carved out" (not included in) the STAR program in the Dallas service area.
OAG
Office of the Attorney General.
OASIS
Outcome and Assessment Information Set.
OBRA
Omnibus Budget Reconciliation Act. Federal Omnibus Budget Reconciliation Act of 1981 created the 1915 (c) waiver programs. Federal Omnibus Budget Reconciliation Act of 1987 reformed rules for nursing facilities participating in Medicare and Medicaid. Federal Omnibus Budget Reconciliation Act of 1990 (OBRA ’90) created the Frail Elderly Program. HB 2292 renamed this program the Community Attendant Services (CAS) program.
OECC
Office of Early Childhood Coordination.
OGC
Office of General Counsel.
OHS
Office of Health Services.
OOA
Older Americans Act.
OIG
Office of the Inspector General.
OT
Occupational Therapy.
Outlier
A statistical term that refers to a data point that is located far from the rest of the data. Given a mean and standard deviation, a statistical distribution expects data points to fall within a specific range. Those that do not are called outliers and should be investigated.
PA
Prior Authorization.
PACE
Program of All Inclusive Care for the Elderly. Provides community-based services to frail elderly people who qualify for nursing facility placement. PACE uses a comprehensive care approach providing an array of services for a capitated monthly fee this is below the cost of comparable institutional care.
PAS
PAS: Where CMS currently uses quality indicators only to identify potential quality problems, QRS also uses them to identify potentially superior performance. QRS recognizes those facilities in which indicator conditions are less common than in 90% of all other facilities. The PAS rates each facility based on the number of indicator conditions that suggest potentially superior performance - each such condition is a potential advantage for residents in that facility. The most favorable PAS rating means that a facility has the most potential advantages.
PAS
Personal Assistance Service. Non-technical attendant care services provided to eligible persons functionally limited in performing activities of daily living. PAS are provided through the Primary Home Care Program.
PAO
Pre-application Orientation - An eligible applicant interested in becoming a waiver program provider, must attend the waiver program provider pre-application orientation (PAO) prior to receiving a program provider application packet.
PASARR
Pre-Admission Screening and Annual Resident Review.
PBM
Pharmacy Benefits Management.
PCCM
Primary Care Case Management.
PCP
Primary Care Physician.
PCS
Provider Claims Services.
PDL
Preferred Drug List.
PDS
CMS uses the quality indicators to identify potential performance problems. That is, CMS advises nursing facilities to look for quality problems whenever an indicator condition is more common in that facility than in 90% of all other facilities. For three of the indicator conditions (Dehydration, Fecal Impaction, and Pressure Sores in Low Risk Residents), CMS recommends looking for quality problems on every occurrence. The PDS rates each facility based on the number of indicator conditions that suggest potential performance problems - each such condition is a potential disadvantage for residents in that facility. The most favorable PDS rating means that a facility has the fewest potential disadvantages.
PDP
Person Directed Plan. A plan developed for a service applicant that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or LAR.
Per Authorization Unit Type
Units approved to equal the cost of the authorized service. This authorization type is associated with the unit rate of one dollar.
Permanency Planning
A philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement, with the primary feature of an enduring and nurturing parental relationship.
Person-Directed Planning 
A process that empowers the individual to direct the development of a plan of supports and services that meets the individual's goals. The process: identifies existing supports and services necessary to achieve the individual's goals; identifies natural supports available to the individual and negotiates needed service system supports; occurs with the support of a group of people chosen by the individual, or their representative; and mirrors the way in which people without disabilities make plans.
Pervasive Developmental Disorders
Pervasive Developmental Disorders, including Autism, Asperger’s Disorder, and Rett’s Disorder, usually begin prior to age 10 and are characterized by severe impairment in the developmental areas of: reciprocal social interaction skills; communication skills, and the presence of stereotyped behaviors, interests, and activities.
PHC
Primary Home Care. PHC is a non-technical, non-medical attendant care service for recipients of all ages whose chronic health problems impair their ability to perform activities of daily living.
PHP
Prepaid Health Plan.
PI
Promoting Independence.
PIAC
Promoting Independence Advisory Committee.
PIN
Payee Identification Number. Also referred to as the Comptroller Vendor ID No., Comptroller Payee ID No., and Texas ID No. The 14-digit number assigned by the State comptroller’s Office to an individual or entity so that the individual or entity can receive funds issued by the State Comptroller’s Office.
PM/PM
Per Member Per Month.
PMAB
Prevention and Management of Aggressive Behavior.
PMO
Project Management Office.
PPO
Preferred Provider Organization.
POS
Place of Service. Identifies the location, (such as a nursing facility, individual’s home, assisted living/residential care facility, or dentist’s office), where the service, (such as daily care, PAS, ERS, assisted living/residential care, and dental services) was provided.
Procedure Code
A code that uniquely identifies a procedure, product, or service provided to the individual. Services provided are described by codes. The following are types of procedure codes:
• Bill codes (also called local codes)
• HCPCS codes
• CPT codes
• American Dental Association (ADA) codes (also called Current Dental Procedural (CDT) codes).
Procedure Code Qualifier
Describes the source of the procedure code entered on the paper or electronic claim. There are three types of procedure code qualifiers:
• ZZ – Texas LTC local codes (usually referred to as a bill code)
• HC – HCPCS or CPT
• AD – American Dental Association codes (or CPT codes)
Program Certification
The point at which an applicant meets the requirements for certification in a waiver program. Each waiver program (HCS and TxHmL) has different certification processes.
Program Provider
An entity that provides waiver program services to persons under a program provider agreement with the Department.
Program Slot
An assigned place in a waiver program.
Provider
A person, group, or agency that has a contract to provide LTC or community service(s) to individuals.
Provisional Certification
A conditional certification for potential waiver providers who attend new certification training and past training test.
PT
Physical Therapy.
QAIS
Quality Assurance and Improvement Plan.
QDWI
Qualified Disabled Working Individual.
QI
Qualified Individual.
QMB
Qualified Medicare Beneficiary.
QMRP
Qualified Mental Retardation Professional. The professional classification of an individual qualified to integrate, coordinate and monitor client treatment programs; also known as case managers.
QRS
Quality Reporting System. A service provided by QAI to allow consumers to evaluate nursing home facilities.
Quality
The degree to which services and supports for individuals and populations increase the likelihood for desired health and quality of life measurable outcomes and are consistent with current professional knowledge. The goal of quality services and supports is to maximize the quality of life, functional independence, health and well being of the population.
Quality Assurance and Improvement (QAI)
A division of DADS.
RAC
Regional Advisory Council.
RAI
Resident Assessment Interview.
RAP
Resident Assessment Protocol.
RAP
Request for Anticipatory Payment.
RC
Related Condition.
RDA
Recommended Daily Allowance.
Real Choice Systems Change
Grants for Community Living that will help states and territories enable people with disabilities to reside in their homes and participate fully in community life. These grants are part of the New Freedom Initiative, a nationwide effort to remove barriers to community living for people of all ages with disabilities and long-term illnesses.
Recipient
One who receives waiver program services.
Related Condition
A severe and chronic disability that: Is attributable to cerebral palsy, epilepsy, or any other condition, other than mental illness, that is closely related to mental retardation because the condition results in impairment in intellectual and adaptive behavior functioning similar to that of person with mental retardation; is manifested before the age of 22; is likely to continue indefinitely; and results in substantial functional limitation in three or more areas of major life activity to include self-care, understanding and using language, learning, mobility, self-direction, and capacity for independent living.
REMEDY
The complaints database used by CSRP.
Reportable Data
Classification of critical incidents requiring provider reporting within 30 days and after the end of the month of occurrence; described in an attachment to the provider’s agreement.
Resolved Complaint
The conclusion of a complaint; the Department has provided a solution, has exhausted all agency authority to resolve the issue, or the complainant no longer has a complaint.
Respite or Respite Care
Services provided to individuals unable to care for themselves. These services are furnished on a short-term basis (up to 45 days per individual service plan year in full or partial day increments as indicated in the individual service plan) because of the absence or need for relief of those persons normally providing the care.
Review
A formal inspection of a waiver provider’s business for compliance with the contract agreement.
Reviewer
Staff conducting a review.
RFO
Request for Offers.
RFP
Request for Proposals.
RPO
Rights Protection Officer. Local contact for complaint mediation for MHMR Centers.
RN
Registered Nurse.
RSDI
Retirement, Survivors and Disability Income.
RSS
Residential Support Services.
RSVP
Retired Senior and Volunteer Program.
RUGS
RUGs. Resource Utilization Group: a 34-44 case-mix classification system that uses data from the MDS form to determine payment. The prospective payment system (PPS) for Medicare reimbursement is based on the RUGs model. The RUGs system is based on data from 1995 and 1997. A proposed new system for the prospective payment system has 53 categories; the new model becomes effective on January 1, 2006.
SAO
State Auditor’s Office.
Sanction
An action taken to limit the ability of an entity to participate in a waiver State health care program, for reasons bearing on the entity's professional competence, professional performance, or financial integrity.
SARC
Sanction Action Review Committee.
SAS
Service Authorization System.
SAVERR
System for Application, Verification, Eligibility Referral and Reporting.
SB
Senate Bill.
SC
Service Coordination/Coordinator.
SCP
Senior Companion Program.
SDA
Service Delivery Area.
Service Authorization
An authorization for an individual to receive a service in a specified period of time from an authorized provider.
Service Code
A code used to denote a specific service or category of service.
Service Coordinator
An employee of an MRA responsible for assisting an applicant, consumer, or LAR to access needed medical, social, educational, and other appropriate services. Service Coordinators help consumers assess their need for services, arrange and coordinate the services, and monitor the services.
Service Planning Team
A planning team constituted by an MRA consisting of an applicant or individual, the LAR, service coordinator, and other persons chosen by the service applicant, individual, or LAR.
SFY
State Fiscal Year.
SHARS
School Health and Related Services.
SHL
Supported Home Living.
SJR
Senate Joint Resolution.
SL
Supervised Living.
SLMB
Specified Low Income Medicare Beneficiary.
SMCAC
Statewide Managed Care Advisory Committee.
SME
Subject Matter Experts. Persons with extensive knowledge about business practices and can identify performance objectives and acceptable performance. They also provide information on what something means or how and what task are performed.
SMI
State Median Income.
SMRF
State Mental Retardation Facility.
SNF
Skilled Nursing Facility.
SO
State Office.
SOM
State Operations Manual. A CMS document that provides CMS policy regarding survey and certification activities.
Spend Down
The process of deducting qualified expenses from income in order to reduce the income to the Medicaid limit.
SPSS
Statistical Package for the Social Sciences. A data management and analysis product. It can perform a variety of data analysis and presentation functions, including statistical analyses and graphical presentation of data.
SRA
Service Responsibility Option.
SRD
System Requirements Document.
SRS
Software Requirements Specification.
SSA
Social Security Administration.
SSDI
Social Security Disability Income.
SSI
Supplemental Security Income.
SSN
Social Security Number.
SSPD/SSPD-24
Special Services to Persons with Disabilities or Special Services to Persons with Disabilities –24 hours. The provisions of services to assist individuals to live in the community. Services include the provisions of 24-hour attendant care services, interpreter services, and adult daycare.
STAR
State of Texas Access Reform.
STAR+PLUS
A Texas Medicaid program designed to integrate delivery of acute and long-term care services through a managed care system.
STP
Significant Traditional Provider.
Support Services
Physical and social modifications or interventions that assist the individual in functioning in and adapting to physical and social environments.
Survey
An examination or inspection of a waiver provider’s business for compliance with the contract agreement.
TAC
Texas Administrative Code. Texas state agency rules.
TAFI
Time and Financial Information. DADS system that collects information for Medicaid administrative claiming and cost reporting.
TANF
Temporary Assistance for Needy Families.
TBNE
Texas Board of Nurse Examiners.
TBPC
Texas Building and Procurement Commission.
TEA
Texas Education Agency. The State of Texas agency funds and regulates the state public education system.
Texas Register
An on-line publication of documents issued by Texas state agencies.
TIERS
Texas Integrated Eligibility Redesign System.
TILE
Texas Index for Level of Effort. The level of effort required by providers to provide the appropriate service(s) to an individual based on an assessment of the individual’s medical need. A TILE is used in the calculation of the payment rate for certain services provided to an individual. There are several different TILEs (values 201 throught 211).
Title I
Grants to States for old age assistance & medical assistance for the aged.
Title II
Federal old age, survivors & disability insurance benefits (OASDI).
Title IV
Grants to States for aid & services to needy families with children (AFDC).
Title X
Grants to States for aid to the blind (AB).
Title XIV
Grants to States for aid to the permanently & totally disabled (DI).
Title XIX
Grants to States for medical assistance programs (MAA)(Medicaid).
Title XVI
Grants to States for aid to the aged, blind and disabled (ABD) & Supplemental Security Income (SSI).
Title XVIII
Health Insurance (Medicare).
Title XX
State operated home health care entitlement program.
Title XXI
State Child Health Programs.
TIN
Tax Identification Number.
TLC
Transition to Living in Community.
TMHP
Texas Medicaid and Healthcare Partnership. TMHP is composed of several businesses under a joint venture with Affiliated Computer Systems (ACS). ACS contracts with HHSC for claims processing for the Texas Medicaid program and to administer the PCCM health plan.
TPI
Texas Provider Identifier.
TPL
Third Party Liability.
TPR
Third Party Recovery.
TRAG
Texas Recommended Authorization Guidelines.
TxHmL
Texas Home Living Program. A Medicaid waiver program that provides community-based services and supports to eligible individuals who live in their own homes or in their family homes operated by the Department.
UM
Utilization Management.
UPL
Upper Payment Limit is the federal limit on the amount of Medicaid payments a state may make to hospitals, nursing facilities, and other classes of providers and plans. Payments in excess of the UPLs do not qualify for federal Medicaid matching funds.
Unit
The authorized amount of service/units provided to the individual. The units are based on the bill code, not the procedure code.
Unit Rate
The dollar amount applied to each unit being billed for the billing code. The number of units multiplied by the applicable unit rate equals the payment amount.
UR/UC
Utilization Review/Utilization Control. A function approving and authorizing eligibility, service levels and reimbursement rates for individuals participating in waiver programs at the time of enrollment, annually, and when a significant change in service needs occurs.
Vacancy
An unoccupied space in a waiver program.
VDP
Vendor Drug Program.
Vendor Hold
A restriction put on a waiter provider that defers claim pay-outs.
WCA
Waiver Contract Area. The Department has grouped the counties into 41 geographical areas, referred to as “local service areas,” each of which is served by a local MRA. The Department has further grouped the local service areas into nine contract areas called WCAs.
Waiver Program
A Medicaid program that provides home and community-based services as an alternative to institutional care in accordance with waiver provisions of the Social Security Act, §1915(c) (42 United States Code §1396n).
Waiver Program Provider Agreement
An agreement between the Department and program provider that obligates the program provider to deliver waiver program services.
Waiting List
A list of persons identified as meeting specific requirements that need mental health and mental retardation services and supports but for whom there is not current funding to provide those services and supports.
WS&C
Waiver Survey & Certification.
A&D Data Mart
Aged and Disabled
ACTS
ASPEN Complaint Tracking System
ASPEN
Automated Survey Processing Environment – A federal automated health information services system used to document deficiencies and violations. All surveys (certified and licensure) are in ASPEN for Home and Community Support Services Agencies (HCSSA).
BHIS
Behavioral Health Information System (BHIS has been upgraded to AVATAR)
CARE
Client Assignment and Registration System – legacy MH/MR mainframe system that provides demographic and other data about individuals served by the Department
CARES
Compliance, Assessment, and Regulatory Enforcement System – legacy DHS system. A comprehensive system built to enable LTCR staff to effectively track, manage, and report information about long term care (LTC) facilities, complaints, investigations, visits, and enforcement actions.
The system provides the following functions: facility licensing and certification tracking; facility surveys; tracking of inspections and investigations; enforcement; complaint tracking; and most state reporting. Most federal reporting is handled through auxiliary interfaced data systems.
CANRS
Client Abuse Neglect Reporting System - The Department’s system that records abuse and neglect allegations. All state facilities and community centers are required to use CANRS.
CANRIS
Client Abuse Neglect Report Inquiry System
CCAD
CDR
Central Data Repository
CMPAS
Consumer Managed Personal Assistance Services
CMS
Claims Management System
CSIL
Community Services Interest List - CSIL tracks applicants as they apply and await services that are, at the time of application, currently unavailable.
ERS
Emergency Response System
EWS
Early Warning System
HCAT
HEART
HHSC is modifying the old TRACK system (now called HEART) and will be consolidating complaints across all HHSC agencies
Integrated
Contains HH surveys
MIS
Management Information System
MMIS
Medicaid Management Information System
OASIS
Outcome and Assessment Information Set - Federal system for gathering data on home health clients.
PAS NE or NE Provider System
CMS Provider System - (PAS) (NE) LTC
QRS
The Quality Reporting System (QRS) provides long term care facility information via a web-based application to members of the public. This includes data related to survey or licensing visits to facilities and deficiencies that were cited during these visits.
OSCAR/ODIE
Online Survey Certification and Reporting System/Online Data Input and Edit System (Federal System) - Data entry of certification survey and complaint investigations at Medicare/Medicaid participating providers.
REMEDY
The complaints database used by Client Rights.
SAS
Service Authorization System - maintains and monitors individuals that have met authorization criteria for programs.
SASO
Service Authorization System Online
SAVERR
System for Application, Verification, Eligibility Referral and Reporting
TIERS
Texas Integrated Eligibility Redesign System – An eligibility determination system.
TMHP
Texas Medicaid and Healthcare Partnership – Medicaid vendor payment system.