A list of frequently utilized acronyms relating to pharmacy reimbursement and their meanings are listed below.
AAC—actual acquisition cost
ABN—advance beneficiary notice
ADAP—Aids Drug Assistance Program
AMP—average manufacturer’s price
APC—ambulatory payment classification
ASC—ambulatory surgical center
ASP—average sales price
BP—best price
CDM—charge description master
CF—conversion factor
CFR—Code of Federal Regulations
CHAMPUS—Civilian Health and Management Program of the Uniformed Services
CMI—case-mix index
CMS—Centers for Medicare and Medicaid Services
COB—coordination of benefits
CORF—comprehensive outpatient rehabilitation facility
CPT—Current Procedural Terminology
DHHS—United States Department of Health and Human Services
DIMA—Medicare Prescription Improvement and Modernization Act
DME—durable medical equipment
DMERC—durable medical equipment carriers
DOS—date of service
DRG—Diagnosis Related Group
DSH—disproportionate share hospital
EDI—electronic data interchange
E/M—evaluation and management services
FFS—Fee-for-Service Program
FI—fiscal intermediary
FUL—federal upper limit price
HHA—home health agency
HI—hospital insurance
HIC—health insurance code
HCPCS—Healthcare Common Procedure Coding System
HOPD—hospital outpatient department
HRSA—Health Resources and Services Administration
ICD-9—International Classification of Diseases, 9th revision
ICD-10—International Classification of Diseases, 10th revision
IPPS—Inpatient Prospective Payment System
LCD—local coverage determinations
LMN—letters of medical necessity
LOS—length of stay
LTC—long term care
MAC—maximum allowable cost
MDC—Major Diagnostic Category
MEDPAR—Medicare Provider analysis and Review
MFS—Medicare fee schedule
MMA—Medicare Modernization Act
MSP—Medicare secondary payer
MR—medical review
NCD—national coverage decision
NOC—not otherwise classified
Non-PAR—nonparticipating provider
OIG—Office of the Inspector General
OPPS—Outpatient Prospective Payment System
PAR—participating provider
PBM—pharmacy benefits management company
PMPM—per-member-per-month
POS—Point of Service Program
PTS—pass-through status
RHC—rural health clinics
RVU—relative value unit
SCOD—specified covered outpatient drugs
SCHIP—State Children’s Health Insurance Plan
SI—status indicators
SMI—supplemental medical insurance
SNF—skilled nursing facility
SSA—Social Security Administration
TEFRA—Tax Equity and Fiscal Responsibility Act
TPA—third party administrator
UB-92—Uniform Bill 1992
UCR—usual, customary, and reasonable
UR—utilization review
UPIN—Unique Physician Identifying Number
WAC—wholesale acquisition cost