Glossary of Terms for Funding Assistive Technology Services and Systems

Glossary of Terms	Definitions	Examples
Appeals Process	The means whereby the ATP can appeal a funding denial.	After you file your appeal, you will receive a letter acknowledging your hearing request. You will eventually receive a date and time for your hearing with an administrative law judge; Medi-Cal is represented by a county representative (non-attorney).
Diagnosis Codes	Describes the person’s condition or medical reason for the services being requested; the key to establishing medical necessity.	Assessment codes include, but are  not limited to: 92540‐92548, 92550, 92552‐92568, 92570 ‐92596, 92601‐ 92604, 92620, 92621, 92625, 92626, 92627, 92640, 92700, 95907‐95913, 95925, 95930, 95937, 95940, 95941, V5008, V5010, V5011, V5014, V5020
Fee for Service	The traditional method of payment for health care under which providers are paid a certain rate per unit of service.	AT assessment costs vary depending on numerous factors, for example: the extent of solutions sought, whether classroom observations are needed, whether a written report is required, and IEP meeting attendance. Formal AT assessments with a written report generally range from $1300 to $2000 -- sometimes less, occasionally more -- depending on the factors mentioned above. Once we discuss the scope of what you need, I can provide an estimate (e.g., "no more than xx hours").
Managed Care	Any method of health care delivery designed to reduce unnecessary utilization of services and provide cost containment while ensuring that high quality care or performance is maintained.	A state's managed care plan must afford individuals with disabilities access to the durable medical equipment and assistive technology that they require to live the most independent, inclusive, and healthy lives feasible in their community of choice. Covered services must include professional assessments of a beneficiary's need for such equipment as well as set-up, maintenance and user training.
Medicaid	A health insurance program, established in 1965 by Title XIX of the Social Security Act, administered at the state level for persons who are unable to pay the costs of their medical care.	Whether a particular AT device or service is covered by a state's Medicaid program will depend upon which categories of service are included in the state plan and how each category of service is defined in federal and state law or policy. Understanding the definitions of the categories of services included in a state's Medicaid plan is the first step is establishing whether a device is actually "covered" by the state.
Medical Necessity	A specific criterion for funding under Medicare, Medicaid, and private insurance that requires identification of a medical diagnosis or condition that is specifically coupled to the functional impairment being addressed by the device.	The Medicaid Act, through the EPSDT benefit, requires states to cover all medically necessary services for Medicaid-eligible children and youth under age 21 and provides an expansive definition of medical necessity for these beneficiaries. Under EPSDT, state Medicaid programs must provide "necessary health care, diagnostic services, treatment and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions." Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening - even if the condition cannot be prevented or cured.
Medicare	The health insurance program operated by the United States federal government, covers individuals age 65 and older and those adults under age 65 who are blind, and totally and permanently disabled and have received Social Security Disability Insurance benefits or Adult Disabled Child benefits for a least 24 months.	Medicare coverage is limited to services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."
Plan for Achieving Self-Sufficiency (PASS)	A program that allows individuals to put aside income for equipment or services that will assist them in achieving a vocational objective.	For example, you could set aside money to go to school to get specialized training for a job or to start a business. A plan is meant to help you get items, services, or skills you need to reach your goals. This can include the Assistive Technology you need! Best of all, the money, saved in a separate bank account designated for the PASS, is disregarded when Social Security is determining your monthly benefit amount.
Procedure Codes	A numerical system used to describe the services that the provider carried out and is billing for; the most commonly used procedure coding system is the Common Procedure Coding System of the Health Care Financing Administration.	97112 Nueromuscular Reeducation: This code is used for seating and access intervention that includes neuromuscular training to improve postural stability/control for function, and/or access issues. This code could be used for the placement of lateral trunk pads, for example. 97504 Orthotics Fitting and Training: This code is utilized for interventions involving splints, corsets, or the fabrication of custom-molded seating systems. This code is used for the hands-on application of the orthotic component, whether for the body or the chair. This code can also be used for training in the use of the custom device. 97530 Therapeutic Activities: This code is utilized for exercise to improve manual wheelchair propulsion, transfers, and posture. This functional code that can be for functional-related wheelchair activities and the practitioner’s documentation should be clear about the functional outcome. 97535 Self Care: This code is utilized for fitting of AT and/or training/positioning which will affect activities of daily life (ADL) and safety. This code may also be used for home environment and modification analysis. This code can be used for power wheelchair training. It is also used for parent/caregiver training. 97537 Community/Work Integration: This code is utilized for access and/or control training involving AT devices, transportation issues, and worksite assessments. It is also used for wheelchair training related to the outdoors, such as negotiating curbs, grass, gravel, inclines, etc. 97542 Wheelchair Management: This code is used for fitting and training of users or caretakers in the use of mobility and seating equipment. This code includes propulsion skills. Due to the low RVU for this code, it is not currently used often, as the reimbursement may not cover the therapist’s actual treatment time costs.
Public Funding Sources	Government funding at the federal, state, or local levels.	The local public school is a public funding source.
Third-Party Payer	Funding source that is public or private and covers the cost of devices and services.	A third party payer is any public or private program, agency or company that pays for the devices or services used by an individual. Public programs are sometimes a source of funding.
Tricare	Formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.	TRICARE coverage to "[a]ny rehabilitative therapy to improve, restore, or maintain function, or to minimize or prevent deterioration of function, of a patient when prescribed by a physician." The existing statute only referenced coverage of "outpatient care," with no specific reference to rehabilitation therapies. This new language expands significantly the range of therapies that will be considered covered benefits for TRICARE enrollees with disabilities and chronic conditions.