Inicio Proveedores & Socios LEA Program Glosario de términos

Glosario de términos del programa LEA

Selecciona una letra para ver los términos que empiezan por esa letra.

Un

Annual Report – All LEAs enrolled in the LEA Medi-Cal Billing Option must submit an “Annual Report” to the Department of Health Care Services each year. The report includes information on LEA Medi-Cal reimbursement, reinvestment expenditures, anticipated reinvestment service priorities, certification of state matching funds, and commitment to reinvest.

C

Cal-SAFE (California School Age Families Education) – The Cal-SAFE program is designed to increase the availability of support services necessary for enrolled expectant/parenting students to improve academic achievement and parenting skills and to provide a quality child care/development program for their children. This comprehensive, continuous, and community-linked school-based program replaces the Pregnant Minors Program (PMP), School Age Parenting and Infant Development (SAPID) Program, and Pregnant and Lactating Students (PALS) Program.

CalWORKs (California Work Opportunity and Responsibility to Kids) – The CalWORKs program provides temporary assistance in the form of cash aid and services to needy families with minor children. The program includes welfare reform measures and services designed to encourage recipients to qualify for and find jobs that will enable families to be self-supporting. Unless exempt, all recipients are required to participate in CalWORKs Welfare-to-Work program as a condition of eligibility.

CCN (Número de Control de Reclamación) : Número asignado a cada reclamación que ingresa al Sistema de Información de Gestión de Medicaid de California. El CCN contiene una fecha juliana que indica la fecha en que se recibió la reclamación.

CCS (California Children's Services) : El Program CCS proporciona servicios de salud a niños elegibles con ciertas limitaciones físicas y afecciones o enfermedades crónicas. CCS cubre servicios médicos, atención hospitalaria y quirúrgica, fisioterapia y terapia ocupacional, análisis de laboratorio, radiografías, aparatos ortopédicos, equipos médicos y gestión de casos médicos. El Program se financia con fondos provenientes de impuestos estatales, del condado y federales, además de algunas cuotas pagadas por los padres.

CHDP (Child Health and Disability Prevention) – The CHDP program provides periodic preventive health services to California children who are Medi-Cal eligible or with family incomes equal to or less than 200% of federal income guidelines. CHDP provides periodic preventive health assessments; children with suspected problems are then referred for diagnosis and treatment.

Child Find – Through the Individuals with Disabilities Education Act of 1997 (IDEA), all children with disabilities residing in the state who are in need of special education and related services must be identified and evaluated to determine if services are required.

CIF (Formulario de Consulta de Reclamaciones) – Este formulario se emplea tras presentar una reclamación para aplicar una de las siguientes cosas: un ajuste por una reclamación mal pagada o sobrepagada, una reconsideración de una reclamación denegada; o un rastreador de una reclamación previamente presentada sin registro de pago o denegación.

CMS (Centros de Servicios de Medicare y Medicaid ) – Anteriormente conocida como Administración de Financiamiento de la Atención Médica (HCFA), CMS es la agencia federal que monitorear Medicare, Medicaid, Program Estatal de Seguro Médico para Niños (SCHIP) y varios otros Program relacionados con la salud.

CRCS (Programa de Reembolso y Comparación de Costos) : todas las LEA inscritas en la Opción de Facturación Medi-Cal para LEA deben presentar un CRCS al Department of Health Care Services. Los proveedores de LEA deben certificar anualmente que los fondos públicos destinados a servicios LEA son elegibles para la participación financiera federal. El CRCS se empleará para comparar los costos reales de cada LEA por los servicios prestados por la LEA con el reembolso de Medi-Cal de la LEA.

D

DHCS (Department of Health Care Services) – La agencia estatal encargada de gestionar el Program Medicaid para el Gobierno Federal.

Diagnosis Codes – All Medi-Cal claims require a diagnosis code. The approved codes may be found in the ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification), a statistical classification system that arranges diseases and injuries into groups according to established criteria.

E

EDS (Electronic Data Systems) – EDS is the Medi-Cal Fiscal Intermediary responsible for processing claims submitted by Medi-Cal providers through a contract with the Department of Health Care Services (DHCS). EDS also provides a variety of support services to Medi-Cal providers.

EPC (Corrección de Pagos Errónea) – Proceso empleado para realizar ajustes en servicios o reclamaciones específicas que se determine que fueron erróneamente sobrepagadas o mal pagadas. El proceso EPC anula la reclamación original, apareciendo como un negativo en el Detalle de Asesoramiento de Remesas del proveedor seguido de una nueva línea de reclamación que muestra la cantidad corregida.

EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) – The EPSDT service is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. The EPSDT program consists of two mutually supportive, operational components: (1) assuring the availability and accessibility of required health care resources and (2) helping Medicaid eligibles and their parents or guardians effectively use these resources. In California, the Child Health and Disability Prevention (CHDP) program provides periodic preventive health services to Medi-Cal eligible children based on the EPSDT program.

F

FFP (Federal Financial Participation) – States must meet certain federal requirements to participate in the Medicaid program. States that meet these requirements receive federal funding in the form of FFP for all Medicaid expenditures.

FFS (Fee-for-Service) – The traditional method of billing for health services under which a health care provider charges separately for each patient encounter or service rendered.

FMAP (Porcentaje Federal de Asistencia Médica) : La parte que le corresponde al gobierno federal de los gastos de un estado en Medicaid. El FMAP se determina anualmente para cada estado.

H

HCPCS (Healthcare Common Procedure Coding System) – HCPCS is a national, uniform coding structure developed by the Centers for Medicare & Medicaid Services (CMS) to standardize the coding systems used to bill for Medicare and Medicaid services on a national basis. All Medi-Cal claims require HCPCS service codes.

Healthy Families – The Healthy Families Program offers low cost insurance for children and teens up to age 19. It provides health, dental, and vision coverage for children who meet the program rules and do not qualify for Medi-Cal. Health Families contracts with selected insurance plans, and program members pay low monthly premiums.

Healthy Start – The Healthy Start program is a state initiative that provides students and their families with links to community resources through school-based family resource centers.

HMO (Health Maintenance Organization) – An organization that assumes responsibility for providing health care to members for a fixed payment without regard to the amount of actual services provided to an individual enrollee. The HMO is responsible for providing most health and medical care services required by enrolled individuals or families, and these services are specified in the contract between the HMO and the enrollees.

Yo

IDEA (Individuals with Disabilities Education Act) – The federal law that mandates that all children with disabilities have available to them a free appropriate public education (FAPE) that includes special education and related services to meet their unique needs. Part B of IDEA provides formula grant assistance to state education agencies for the education of children with disabilities, ages three through 21. Part C of IDEA provides funds to state lead agencies to assist in the provision of early intervention services to infant and toddlers with disabilities, ages birth through two.

IEP (Individualized Education Plan) – A legal agreement composed by educational professionals, with input from the child’s parents, for students identified as disabled in accordance with IDEA requirements. This agreement guides, coordinates, and documents instruction that is specially designed to meet the student’s unique needs.

IFSP (Individualized Family Service Plan) – A written plan for providing early intervention services to a child eligible under IDEA and the child’s family. The IFSP enables the family and service provider(s) to work together as equal partners in determining the early intervention services that are required for the child with disabilities and the family.

L

LEA (Local Education Agency) – The governing body of any school district or community college district, the County Office of Education, a state special school, a California State University campus, or a University of California.

LEA Collaborative – A collaborative interagency human services group (local collaborative) at the county level or sub-county level that makes decisions about the reinvestment of funds made available through the LEA Medi-Cal Billing Option. Generally, representation will include the schools, major public agencies serving children and families including health, mental health, social services and juvenile justice, the courts, civic and business leadership, the advocacy community, parents or guardians, and current safety net and traditional health care providers.

LEA Medi-Cal Billing Option – A program for LEAs to bill Medi-Cal for specific health and medical services provided to students and their families in the school setting. Services provided through this program include assessments, treatments, and Targeted Case Management.

LEC (Consorcio de Educación Local) : una agencia educativa local que coordina las actividades administrativas de Medi-Cal (MAA) para una de las 11 regiones de servicio de la Asociación de Servicios Educativos de los Superintendentes de Condado de California (CCSESA). Las LEAS deben reclamar la MAA a través de la LEC de su región respectiva o de su agencia local de salud pública o del condado (también conocida como Agencia de Gobierno Local o LGA). >

M

MAA (Medi-Cal Administrative Activities) – A program for LEAs to be reimbursed for staff activities necessary for the proper and efficient administration of the Medi-Cal program. The amount of reimbursement is based on an operational plan and periodic time surveys. The MAA program is separate from the LEA Medi-Cal Billing Option.

Managed Care – A health care delivery system that provides services within a defined network of health care providers who are given the responsibility to manage and provide quality, cost-effective health care. Managed care plans, which may include but are not limited to Health Maintenance Organizations (HMOs), typically receive a prepaid rate for each member enrolled in the plan.

Match – The portion of the cost of providing a LEA Medi-Cal service that is not reimbursed by the federal government. In the LEA Medi-Cal Billing Option, school districts receive only the federal portion of the reimbursement rate. When they enroll and in each subsequent annual report, LEAs certify that they will pay the match for the federal share for LEA services.

Medicaid – A federal program established in 1965 under Title XIX of the Social Security Act and jointly funded by the Federal and State governments. Medicaid provides health care coverage for low-income families; aged, blind, and disabled persons; and individuals whose income and resources are insufficient to meet the costs of necessary medical services. Medi-Cal is California’s Medicaid program and is administered by the Department of Health Care Services (DHCS).

Medi-Cal Eligibility Data Match – A process established for LEAs to obtain verification of Medi-Cal eligibility for enrolled students.

Medicare – A federal program, established in 1965 under Title XVIII of the Social Security Act. Medicare provides health care coverage for people age 65 or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.

N

NPI (Identificador Nacional de Proveedores) – Número único nacional de identificación de proveedor de 10 dígitos que cumple con la Ley de Portabilidad y Responsabilidad de Seguros de Salud (HIPAA).

O

OIG (Oficina del Inspector General) – La OIG protege la integridad de Program gestionados por el Departamento de Salud y Servicios Humanos de los Estados Unidos (HHS), así como la salud y el bienestar de los beneficiarios de dichos Program. El Departamento de Salud y Servicios Humanos (HHS) proporciona financiación para servicios humanos esenciales en más de 300 Program, incluidos Medicare y Medicaid. Las funciones de la OIG se llevan a cabo a través de una red nacional de auditorías e investigaciones del Program del HHS.

OMB Circular A-87 (Office of Management and Budget) – A codified Federal Executive Branch regulation that provides mechanisms and guidelines for state and local governments for accounting for costs when administering federal programs.

P

PPA (Provider Participation Agreement) – The Provider Participation Agreement (PPA) is the contract through which qualified Local Educational Agencies enroll to participate in the LEA Medi-Cal Billing Option.

R

RAD (Remittance Advice Details) – A report listing provider claims that have been paid for a particular payment period. The RAD is used by providers to reconcile their records with claims that have been paid, denied or suspended.

S

SNF (Safety Net Financing Division) – SNFD gestiona los pagos suplementarios de conformidad con la exención de Medicaid de la Sección 1115 "Bridge to Reform" y el Plan Estatal de Medicaid. La Sección de Pagos Suplementarios Medi-Cal (MSPS) procesa y monitorear los pagos a hospitales y otros tipos de proveedores para diversos Program suplementarios y gestiona el Program Tarifas de Garantía de Calidad Hospitalaria (QAF). La Sección de Demostración y Atención Subaguda para Hospitales/Personas sin Seguro (HUDSS, por sus siglas en inglés) evalúa los costos y tarifas de los hospitales públicos designados y monitorear la exención integral de California. La Sección de Grupos Relacionados con el Diagnóstico (DRG, por sus siglas en inglés) monitorear la implementación de la metodología de reembolso del hospital para pacientes internados y gestiona el Program de Cuidados Subagudos. La Rama de Reclamaciones Administrativas, Servicios Locales y Escolares proporciona reembolsos federales a condados y distritos escolares por actividades administrativas, gestión de casos dirigida y ciertos servicios escolares médicamente necesarios. La Rama de Financiación Hospitalaria de Participación Desproporcionada y Recuperación Hospitalaria No Contractual (DSH) reembolsa a los hospitales elegibles los costos de atención no compensados de los servicios hospitalarios y recupera los pagos en exceso de los servicios hospitalarios de hospitalización proporcionados por hospitales no contratados.

SCHIP ( Program Estatal de Seguro Médico para Niños) : un Program federal, similar a Medicaid, establecido en 1997 bajo el Título XXI de la Ley de Seguridad Social. SCHIP proporciona seguro médico a niños cuyas familias ganan demasiado dinero para ser elegibles para Medicaid, pero no lo suficiente como para comprar un seguro médico privado. El Program de Californiase llama Program de Familias Saludables y es gestionado por la Junta de Seguros Médicos de Riesgo Gestionado (MRMIB, por sus siglas en inglés).

Section 504 Accommodations – Section 504 of the Rehabilitation Act of 1973 requires school districts to provide or pay for certain services to make education accessible to handicapped children. These services are described in an Individualized Health Service Plan (IHSP) or 504 Plan.

Agencia Estatal Única – La agencia estatal encargada de gestionar el Program Medicaid . En California, la única agencia estatal es el Department of Health Care Services (DHCS)) y el Program Medicaid se llama Medi-Cal.

SSI (Ingreso de Seguridad Suplementario) : un Program federal de asistencia económica para personas mayores, ciegas o discapacitadas de bajos ingresos, establecido por el Título XVI de la Ley de Seguridad Social. Los estados pueden emplear los límites de ingresos del SSI para determinar la elegibilidad para Medicaid.

State Plan – A written plan between a State and the Federal Government that outlines Medicaid eligibility standards, provider requirements, payment methods, and health benefit packages. A Medicaid State Plan is submitted by each State and approved by the Centers for Medicare & Medicaid Services (CMS).

SPA (State Plan Amendment) – States may submit amendments to their Medicaid State Plans to change eligibility standards, provider requirements, payment methods, or health benefit packages. The amendments are reviewed and processed according to specific statutory timelines by the Centers for Medicare & Medicaid Services (CMS) Regional Offices with consultation and review by the CMS Central Office, if necessary.

T

TANF (Asistencia Temporal para Familias Necesitadas) : un Program federal de asistencia económica a nivel estatal para familias de bajos ingresos. TANF sustituye al antiguo Program conocido como Ayuda a Familias con Hijos Dependientes (AFDC). CalWORKs es el nombre del Program TANF de California .

TCM (Targeted Case Management) – LEA Medi-Cal TCM services assist eligible children and eligible family members to access needed medical, social, educational and other services when TCM is covered by the student’s IEP or IFSP. The components of TCM include: Determining needs, Developing a plan, Linking & consulting coordination, Accessing services outside the school system, Assisting with crises, and Reviewing Progress.

U

UB 04 – This form is used to submit claims for Outpatient Medi-Cal services, including LEA Medi-Cal Billing Option services.

Glosario de términos del programa LEA​​

Glosario de términos del programa LEA