Section VII - Glossary

A. Definition of Terms

Term	Definition
Adjustment	A change to the paid amount on a previously reported record. Adjustments do not include changes due to data reporting errors.
Administering Entity	The insurance carrier, Third Party Administrator, bill review vendor, or other entity that receives the bill from a medical service provider and that pays for the medical transaction.
Ambulatory Surgical Center (ASC)	A state-licensed facility that is used mainly to perform outpatient surgery, has a staff of physicians, has continuous physician and nursing care, and does not provide for overnight stays. An ambulatory surgical center can bill for facility fees much like a hospital, but generally has a separate fee schedule.
ASC	See Ambulatory Surgical Center.
ASCII	(American Standard Code for Information Interchange) standard code for representing characters as binary numbers. In addition to printable characters, the ASCII code includes control characters to indicate carriage return, backspace, and the like.
Bill	A listing (lines) of charges for medical services. A bill may consist of multiple lines.
Calendar Year Premium	Associated with premium within a given calendar year period. Calendar year premium is final at the end of the period and does not change from valuation to valuation.
Cancellation	A Medical Data Call transaction that allows the medical data provider to completely remove a previously submitted record or multiple records from the PCRB’s database.
Carrier	See Insurance Carrier
Carrier Group	Insurance companies under a common ownership
Claim	A demand to recover from a loss or damage covered by a policy of insurance. A Medical Data Call claim (identified by claim number) includes one or more bills for medical services.
Claimant	The person who makes a claim. The claimant receives the medical services listed on the bill(s) for the associated claim.
CMS-1500 Form	The standard claim form of the Centers for Medicare and Medicaid Services used by non-institutional providers or suppliers to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of some Medicaid State Agencies.
Count Occurrences	A mechanism for tracking record level edits that pass or fail. During File Acceptance processing, all edits with an outcome of Count Occurrences that fail will cause the record to be rejected and returned to the data submitter. Quality Tracking edits with an outcome of Count Occurrences that fail will always be displayed as a percentage of the total records. Quarter End Validation edits with an outcome of Count Occurrences that fail will be displayed as a percentage of total records when the result exceeds the tolerance level.
Coverage Provider (or Coverage Provider Group)	See Insurance Carrier.
Data Element	The smallest unit of physical data for which attributes are defined.
Deductible	A clause in an insurance policy that relieves the insurer of responsibility in dollars, percentage of the total, or percentage of the loss before paying the loss.
Field	An area designated for a particular category of data.
File	An organized, named collection of related records packaged collectively and reported electronically to the PCRB. For Medical Call data, a file may only include the data from one reporting group, but data for multiple carrier codes within the reporting group is acceptable.
Gross Premium	In company language, the premium before deducting any premium paid for reinsurance and, in some cases, before paying any return premium.
Health Maintenance Organization (HMO)	An organization of medical care providers that offers a specified range of medical care in return for a set fee. See also Preferred Provider Organization.
HMO	See Health Maintenance Organization.
Individual Reporter	A medical data provider that reports data only for its own carrier code. Data will not be included in a file for other carrier codes.
Insurance Carrier	The company that issues the insurance policy. Also referred to as the coverage provider. Insurance carriers include private carriers, state funds, and self-insured groups.
Insured	The policyholder. In workers compensation insurance, the insured is the person or organization (employer) that is protected (covered) by the insurance policy and is entitled to recover benefits under its terms. The insured is designated in Item 1 of the policy Information Page.
Insurer	The insurance carrier or other organization, such as a syndicate, pool, or association, providing insurance coverage and services.
Line	A single charge for a medical service or services listed on a bill. Also referred to as line item detail.
Medical Data Provider	Any unique data reporting entity that is certified to send Medical Call data to the PCRB. This includes, but may not be limited to, insurance carriers, Third Party Administrators (TPAs), bill review vendors, and pharmacy vendors. See also Reporting Group.
Medical/Service Provider	See Service Provider.
Patient	The person receiving medical services. For a workers compensation claim, the patient is also the claimant.
Payer	The entity that ultimately pays for medical services.
Policy	The formal written contract of insurance between the employer (insured) and the insurance carrier (insurer).
PPO	See Preferred Provider Organization.
Preferred Provider Organization (PPO)	A network of medical care providers contracted by the insurer to provide various medical care services to covered employees for specified fees. The covered employees have the option to go to the network of medical care providers or to go outside of the network for medical care services for reasonable and customary fees after a set deductible is met. See also Health Maintenance Organization.
Provider	See Service Provider.
Quarterly Submission	The data file, or files that represent the reporting group’s aggregate submission for a given three-month (quarter) period.
Record	A collection of related data elements that are treated as one unit.
Record Layout	Defines the parameters for each data field contained in the record that is submitted electronically, including the data field’s starting and ending positions on the record and the field’s specific type/class (i.e., alpha, numeric, or alpha/numeric). The consistent parameters allow for efficient processing, so the data contained within can be sorted, formatted, and customized.
Reporting Group	An affiliated insurance company or an assembly of affiliated insurance companies (Affiliate Carrier Group) and their designated medical data providers that report Medical Call data to the PCRB.
Service Provider	Service provider, or medical service provider, refers to the individual or group that furnishes a patient with various medical services (e.g., physician, clinic, hospital, pharmacy). Refer to Data Dictionary Provider Taxonomy Code for the source link to the accepted Provider Taxonomy Code list.
Special Characters	Refers to the additional characters other than letters A–Z and numbers 0–9.
Statistical Agent	Company associations that collect workers compensation data and prepare it according to rating regulation requirements on behalf of their members. Most state workers compensation laws permit companies to join together for this purpose.
Submission	A file transmitted to the PCRB for a given reporting group. Also referred to as a transmission.
Subsidiary	A corporation that is either wholly owned by another corporation or controlled by a corporation or business entity that owns a majority of its voting shares.
Third Party Administrator (TPA)	An organization hired to perform one or more of the business functions of another company, which may include reporting insurance data to the statistical agent.
TPA	See Third Party Administrator.
Transaction	Refers to either of the following: • The line item of a medical bill. Referred to as a medical transaction in this manual. Use this definition for Transaction Date. • The general term given to data transmitted from one computer system to another for the purpose of accessing, querying, or updating a record, file, or database. Use this definition for Transaction Code.
Transmission	See Submission.
UB-04 Form	The basic form that Centers for Medicare and Medicaid Services prescribes for the Medicare program. It is only accepted from institutional providers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act (ASCA), Public Law 107105, and the implementing regulation at 42 CFR 424.32.
Unit Statistical Data	The statistical documentation that insurance carriers submit to the PCRB for the purpose of reporting workers compensation insurance data. It includes premium and losses by state at a classification code level.
Utilization	The frequency that a particular medical procedure is performed.
Workers Compensation Insurance	Statutory coverage for employers subject to the workers compensation law of a state. It provides benefits to employees who are injured during the course of their employment. The Pennsylvania Workers Compensation Manual of Rules, Classifications and Rating Values for Workers Compensation and for Employers Liability Insurance contains rules, classifications with descriptions, rates/loss costs for each classification, and state-specific exceptions for writing workers compensation insurance.