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An acquisition or merger occurs when two or more facilities combine with one tax identification number (TIN) and one Medicare provider identification number (PIN). One or more TIN(s) and PIN(s) must be terminated at this time. The acquired and acquiring providers must submit separate CMS 855A applications. (See also: CMS 855A)
Activities of Daily Living (ADL)
Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.
The amount a physician or supplier actually bills a patient for a particular medical service or supply. (This may differ from the customary, prevailing, and/or reasonable charges under Medicare.)
Additional Development Request (ADR)
A request for additional information on Medicare A and Medicare B claims before final payment determination is made.
Administrative Law Judge (ALJ)
One who presides at an administrative hearing, with power to administer oaths, take testimony, rule on questions of evidence and make agency determinations of fact. Formerly called “hearing examiner.”
Advance Beneficiary Notice (ABN)
A notice that a doctor or supplier should give a Medicare beneficiary to sign in the following cases: Your doctor gives beneficiary a service that he or she believes that Medicare does not consider medically necessary; and doctor gives beneficiary a service that he or she believes that Medicare will not pay for.
A Medicare carrier, FI, or other contractor such as a Durable Medical Equipment Regional Carrier (DMERC), which shares some or all of the PSC’s jurisdiction in which the affiliated contractor performs non-PSC Medicare functions such as claims processing or education
Alternate Delivery Systems (ADS)
A means of offering choices or options in modes of health care, often reducing costs but not quality of care. Examples of alternative delivery systems are health maintenance organizations, outpatient diagnostic services and preferred provider organizations.
Outpatient health care provided to patients who do not need to occupy an inpatient, acute care hospital bed. The words ambulatory and outpatient are often used interchangeably.
Ambulatory Payment Classification (APC)
Payments made under the Outpatient Prospective Payment System (OPPS) are based on the ambulatory payment classification system, which divides all outpatient services included in the payment schedule into groups.