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Glossary

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Applicant Type

Application type description chosen for Individual providers in the Basic Information Step.

Application: Provider’s enrollment

Digital form to be submitted for enrollment into Illinois Medicaid.

Application ID

A system generated number which a provider must use to locate their enrollment during revalidation or track their application in the system.

Association

An action taken by a provider to link themselves to an FAO, Group, and atypical agency providers.

Atypical Provider

A provider who is delivering services to Medicaid clients that are not considered to be health care services. These providers are not required to obtain an NPI (National Provider Identifier). The Centers for Medicare and Medicaid Services (CMS) defines Atypical Providers as providers that do not provide health care. This is further defined under HIPAA in Federal regulations at 45 CFR 160.103. Taxi services, home and vehicle modifications, and respite services are examples of Atypical Providers reimbursed by the Medicaid program. Even if these Atypical Providers submit HIPAA transactions, they still do not meet the HIPAA definition of health care and should not receive an NPI number.

Atypical Individual Provider (AI)

A Sole Proprietor or Rendering/Servicing provider who is not required to obtain an NPI (National Provider Identifier) to enroll in the IMPACT system

Atypical Agency Provider (AA)

A facility, agency, or organization that is not required to obtain an NPI (National Provider Identifier).

Billing Agent

A business authorized to submit Medicaid HIPAA compliant transactions; an entity who exchanges Electronic Protected Health Information (ePHI) on behalf of Medicaid Providers or other authorized parties. They may also be referred to as a Clearinghouse, Software Vendor, or Value-Added Network (VAN) depending on their relationship to the health care provider.

Billing Provider

A provider who submits claims and/or receives payments for an Individual Rendering/Servicing or Sole Proprietor provider. Formerly referred to as alternate payee.

Clearinghouse

A Clearinghouse is the business authorized to submit Medicaid HIPAA compliant transactions; an entity who exchanges Electronic Protected Health Information (ePHI) on behalf of Medicaid Providers or other authorized parties. They may also be referred to as a Billing Agent, Software Vendor, or Value-Added Network (VAN) depending on their relationship to the health care provider.

Comptroller

The state agency which certifies the validity of a TIN (Tax Identification Number) as reported by the provider. All TINs must be certified by the Comptroller prior to enrollment into IMPACT.

Correspondence Address

The address used to send enrolled Medicaid providers written information, i.e., Correspondence.

DentaQuest

Is an oral health care company that manages dental benefits for 30 + million Americans. They provide cost effective dental solutions for Medicaid and CHIP, Medicare Advantage, and businesses nationwide.

Disregarded Entity An LLC which has elected to not be separated from its owner for tax purposes, which means that it will not have its own TIN for enrollment into IMPACT. There is a work around for this issue and can be found in the PES Library W9 Folder.
Domain Administrator Assigns and takes away users’ access to an enrollment. The role/profile granted to the Single Sign-On account which submits the provider enrollment application just prior to approval. Can be assigned to other sign-on accounts as needed.

Enrollment Type

The Enrollment Type categorizes provider types to help identify additional enrollment requirements. (Examples of Enrollment Types are Group, Facility, Billing Individual, Individual within a Group, Atypical, and Ordering/Prescribing/Referring)

Enrollment Checklist

A list of questions which the provider is required to answer as they work through their enrollment into IMPACT. Actions may be required based on the answers given.

Group

A provider organization that serves as a payee or billing provider for individual providers. A group will require a Type 2 NPI and cannot serve as a rendering provider. No licensing is required for this type of organization

Healthcare Provider

A provider of services as defined in section 1861(u) of the Act, 42 U.S.C. 1395X(u), a provider of medical or health services as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.

IMPACT

Illinois Medicaid Provider Advanced Cloud Technology: the web-based system by which provider can enroll to be a Medicaid provide

Individual Rendering/Servicing Provider

A provider, who orders, prescribes, or refers items or services through a Group, Facility, Agency, Organization (FAO) or an Individual/Sole Proprietor. A Rendering/Servicing provider does not bill directly to Medicaid.

Pay-to Address

Associated to the entity paid by Medicaid. One pay-to address is entered in IMPACT per FEIN.

Provider Type

Indicates what “kind” of provider is doing the billing. Provider types include individuals and facilities.

Remittance Address

An address that businesses use, which can be different from the main mailing address to receive payments.

Rendering/Servicing Provider

An individual provider who will be rendering services to Medicaid clients but will not be submitting claims directly to the state for reimbursement.

Revalidation

The process when a person or entity currently enrolled with Illinois Medicaid verifies and updates their enrollment information on file in the IMPACT system.

Risk Assessment Level

Set by OIG and federal guidelines as High, moderate, or Limited. High Risk-requires site visit and fingerprinting.

Moderate risk-requires site visit. Limited-Nothing extra necessary

Service Location

The location(s) where services are rendered.

Software Vendor

A Software Vendor is the business authorized to submit Medicaid HIPAA compliant transactions; an entity who exchanges Electronic Protected

  Health Information (ePHI) on behalf of Medicaid Providers or other authorized parties. They may also be referred to as a Billing Agent, Clearinghouse, or Value-Added Network (VAN) depending on their relationship to the health care provider.

Specialty

The provider’s specialty is a value indicating what field of medicine a provider has additional education in to make him/her a specialist in a certain field.

State (Sister) Agencies

A core group of State of Illinois agencies and program areas involved in and affected by the IMPACT system.

Taxonomy Code

An alphanumeric 10-character code selected by the health care provider based upon their education, license/certification and the services being rendered. This code is used in billing HIPPA related transactions and is required when applying for a National Provider Identifier Number. The code is structured into 3 distinct levels including Provider Type, Classification and Area of specification.