LEA Program Glossary of Terms
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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.
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 (Claim Control Number) – Number assigned to each claim that enters the California Medicaid Management Information System. The CCN contains a Julian date indicating the date the claim was received.
CCS (California Children's Services) - The CCS program provides health services to eligible children with certain physical limitations and chronic health conditions or diseases. CCS covers doctor services, hospital care and surgical care, physical and occupational therapy, laboratory tests, X-rays, orthopedic appliances, medical equipment, and medical case management. The program is funded with state, county, and federal tax monies, along with some fees paid by parents.
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 (Claims Inquiry Form) - This form is used after submitting a claim to request one of the following: an adjustment for either an underpaid or overpaid claim, reconsideration of a denied claim; or a tracer of a previously submitted claim with no record of payment or denial.
CMS (Centers for Medicare & Medicaid Services) - Formerly known as the Health Care Financing Administration (HCFA), CMS is the federal agency that oversees the Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), and several other health-related programs.
CRCS (Cost Reimbursement and Comparison Schedule) - All LEAs enrolled in the LEA Medi-Cal Billing Option must submit a CRCS to the Department of Health Care Services. LEA providers must annually certify that the public funds expended for LEA services are eligible for federal financial participation. The CRCS will be used to compare each LEA’s actual costs for LEA services to the LEAs Medi-Cal reimbursement.
DHCS (Department of Health Care Services) - The State agency charged with administering the Medicaid program for the Federal Government.
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.
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 (Erroneous Payment Correction) –
Process used to make adjustments for specific services or claims determined to have been erroneously overpaid or underpaid. The EPC process voids the original claim, appearing as a negative on the provider’s Remittance Advice Detail followed by a new claim line showing the corrected amount.
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.
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 (Federal Medical Assistance Percentage) – The federal government’s share of a state’s expenditures for Medicaid. The FMAP is determined annually for each state.
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.
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.
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 (Local Education Consortium) - An LEA coordinating Medi-Cal Administrative Activities (MAA) for one of the 11 service regions of the California County Superintendents Educational Services Association (CCSESA). LEAs must claim for MAA through their respective region’s LEC or their local public health or county agency (also referred to as a Local Governmental Agency or LGA). >
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.
NPI (National Provider Identifier) - Unique national 10-digit provider identification number that is Health Insurance Portability and Accountability Act (HIPAA) compliant.
OIG (Office of Inspector General) - The OIG protects the integrity of programs administered by the U.S. Department of Health and Human Services (HHS), as well as the health and welfare of the beneficiaries of those programs. HHS provides funding for essential human services in more than 300 programs, including Medicare and Medicaid. The OIG’s duties are carried out through a nationwide network of audits and investigations of HHS programs.
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.
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.
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.
SNF (Safety Net Financing Division) – SNFD administers supplemental payments in accordance with the “Bridge to Reform” Section 1115 Medicaid Waiver and the Medicaid State Plan. The Medi-Cal Supplemental Payments Section (MSPS) processes and monitors payments for hospitals and other type of providers for various supplemental programs and administers the Hospital Quality Assurance Fee (QAF) program. The Hospital/Uninsured Demonstration and Subacute Section (HUDSS) evaluates designated public hospital costs and rates and oversees California’s comprehensive waiver. The Diagnosis Related Group Section (DRG) oversees the implementation of the inpatient hospital’s reimbursement methodology and administers the Subacute Care Program. The Administrative Claiming, Local and School Services Branch provides federal reimbursement to counties and school districts for administrative activities, targeted case management and certain medically necessary school-based services. The Disproportionate Share Hospital Financing and Non-Contract Hospital Recoupment Branch (DSH) reimburses eligible hospitals for uncompensated care costs for hospital services and recoups overpayments for inpatient hospital services provided by non-contract hospitals.
SCHIP (State Children's Health Insurance Program) - A federal program, similar to Medicaid, established in 1997 under Title XXI of the Social Security Act. SCHIP provides health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private health insurance. California’s program is called the Healthy Families Program and is administered by the Managed Risk Medical Insurance Board (MRMIB).
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.
Single State Agency - The state agency charged with administering the Medicaid program. In California, the single state agency is the Department of Health Care Services (DHCS) and the Medicaid program is called Medi-Cal.
SSI (Supplemental Security Income) - A federal cash assistance program for low-income aged, blind or disabled individuals established by Title XVI of the Social Security Act. States may use SSI income limits to establish Medicaid eligibility.
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.
TANF (Temporary Assistance for Needy Families) - A State-based federal cash assistance program for low-income families. TANF replaces the former program known as Aid to Families with Dependent Children (AFDC). CalWORKs is the name of California’s TANF program.
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.
UB 04 –
This form is used to submit claims for Outpatient Medi-Cal services, including LEA Medi-Cal Billing Option services.
