ATT001_TPA_Glossary.xlsx
XLSX spreadsheet 65 KB Posted
- Solicitation number
- 75D301-24-RFI-WTCHP-TPA
About this file
This document is a draft Performance Work Statement (PWS) for a planned solicitation to award a contract for a Third-Party Administrator (TPA) for the World Trade Center (WTC) Health Program. The WTC Health Program is a federal healthcare program that provides medical monitoring and treatment for WTC-related health conditions to eligible responders and survivors affected by the 9/11 attacks.
The key details provided in the draft PWS include: an overview of the WTC Health Program and the TPA's role; descriptions of the TPA's required services such as enrollment, certification, claims processing, provider network management, and member services; data summary and volume information to be provided with the solicitation; and questions for industry feedback on items such as required information, incentives, contract structure, and evaluation factors. The government plans to release the solicitation in mid-January 2025, with contract award expected in September 2025. Interested parties are invited to provide written feedback on the draft PWS and respond to the specific questions by October 25, 2024.
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Other files
| File | Type | Posted |
|---|---|---|
| ATT101_TPA_SummaryVolumeData_Shell.xlsx | XLSX spreadsheet | |
| ATT015_TPA_ProcessFlow_Transfer.pdf | ||
| ATT012_TPA_ProcessFlow_Enrollment.pdf | ||
| Questions and answers template.xlsx | XLSX spreadsheet | |
| WTC Health Program TPA draft PWS.docx | DOCX document | |
| ATT013_TPA_ProcessFlow_Certification.pdf |
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Overview
This glossary contains brief descriptions of key terms relevant to the Third-Party Administrator, serving as a supplemental reference tool for terms encountered in the Performance Work Statement and/or other documents provided in the solicitation to provide additional context. The acronym library provides common acronyms and the correlating full expansion of the abbreviated word or term. Not all terms in the glossary are in the acronym library, and vice versa.
Attachment Notes:
Descriptions in this document do not supersede or replace contractual definitions found in the PWS nor regulatory definitions such as those found in the Admin Manual, and are generally more plain language in nature, with additional contextual details beyond the definition to provide clarity.
Glossary
| Term | Description |
| Abuse (FWA) | Practices that may directly or indirectly result in unnecessary costs to the Program; includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care. Examples include 1) billing for services that were not medically necessary; 2) charging excessively for services or supplies; and 3) coding and billing for one hour when the visit was only 15 minutes |
| Acceptable Quality Level | Minimum performance threshold(s) that the Program is willing to accept for each outlined performance standard in the Quality Assurance Surveillance Plan |
| Acceptance and Performance Testing Phase | Transition-In contract phase wherein the TPA Contractor, the Program, and other Program contractors coordinate to simulate full, end-to-end operations across the Contractor’s scope of services for the purposes of evaluating the consistency and accuracy of the results and make sure that the system(s) work correctly. This phase is also referred to as a "dry run" in the PWS. |
| Acute Traumatic Injuries | One of the five Zadroga Condition Categories; conditions characterized by physical damage to the body caused by hazards or adverse conditions |
| Adequate Security | Protective measures that are commensurate with the consequences and probability of loss, misuse, or unauthorized access to, or modification of information |
| Aerodigestive Disorders | One of the five Zadroga Condition Categories; airway and digestive disorders that affect breathing airways, such as the sinuses or lungs, or upper digestive tract, such as the esophagus |
| Ancillary Condition | A health condition that does not meet the requirements for certification under the Program, but must be treated in order to manage, ameliorate or cure a certified WTC-related health condition or medically associated condition. The Program does not require certification of the ancillary condition and covers ancillary condition care using the principle of medically necessary treatment |
| Annual Monitoring Exam | Detailed yearly health exam of a WTC Responder or Certified-Eligible Survivor that looks for WTC-related physical and mental health conditions. Findings help determine whether a member has a condition that can be certified for treatment in the WTC Health Program and are used for long-term health monitoring and analysis. It includes the same components as the Initial Health Evaluation and first Annual Monitoring Exam, except for the exposure assessment |
| Appeal | To formally challenge a decision made by the Program to not enroll an applicant or to disenroll a member, to not certify a health condition or to decertify a health condition, or to not cover a treatment |
| Appellant | An individual that has submitted an appeal to the Program to reverse an enrollment, certification, or treatment denial decision or a disenrollment or decertification decision |
| Applicant | An individual that has applied to the Program for enrollment but has not yet received a final decision on their eligibility status or has been notified that they are not eligible for enrollment based on their 9/11 exposure |
| Authorization to Operate | The official management decision issued by a designated accrediting authority (DAA) or principal accrediting authority (PAA) to authorize operation of an information system and to explicitly accept the residual risk to agency operations (including mission, functions, image, or reputation), agency assets, or individuals |
| Benefit Administration | Services performed on behalf of the Program to ensure coverage of medical services aligned with limited benefit requirements |
| Benefit Plan | Grouping developed by the WTC Health Program that defines the acceptable ranges of care for specific categories of covered health conditions. The WTC Health Program offers multiple benefit plans, which are open to members based on their status as defined in the Act (e.g., responder or survivor) and their certified health condition(s) |
| Benefits Counseling | A service available to members where a CCE/NPA staff person informs them about various benefits that they might be eligible for and assists them in applying for those benefits. Benefits counseling includes all Program benefits, changes to benefits, and information on workers’ compensation, other health insurance, the September 11th Victim Compensation Fund, health insurance under the Affordable Care Act, and social services |
| Benefits Eligibility Assessment and Screening Tool | An electronic tool that generates a customized benefits counseling plan for an individual member based on the member’s responses to the questions posed by the tool to determine eligibility and applicability |
| Billing Provider | Person or entity who submits claims for reimbursement (as opposed to the rendering provider) |
| Breach (Data) | An incident that involves sensitive, protected, or confidential information being copied, transmitted, viewed, stolen, or used by an individual unauthorized to do so |
| Breach (PHI) | The acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E of 45 CFR 164 which compromises the security or privacy of the protected health information |
| Breach (PII) | The loss of control, compromise, unauthorized disclosure, unauthorized acquisition, or any similar occurrence where 1) a person other than an authorized user accesses or potentially accesses data or 2) an authorized user accesses or potentially accesses data for an other than authorized purpose |
| Business Associate | A person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. The TPA Contractor serves as a Business Associate of the WTC Health Program, a covered entity |
| Business Days | Monday through Friday, except for designated Federal holidays |
| Calendar Days | Monday through Sunday, including designated Federal holidays |
| Calendar Year | A year cycle based on the calendar, starting January 1 and ending December 31 |
| Cancer Latency | The amount of time between the initial date of an individual's 9/11 exposure and the date of the initial diagnosis of the individual's cancer. Minimum latency requirements must be met in order for a member's cancer to be certified by the Program |
| Cancers | One of the five Zadroga Condition Categories; conditions resulting from unctrolled growth and spread of cells, that make it difficult for the body to function normally |
| CCE-affiliated Network Providers | Providers within a NYMA-based Clinical Center of Excellence who use internal CCE systems and staff for administrative support such as claims processing, and provide care to WTC Health Program members under the direct oversight of the CCE Medical Director |
| Centers for Medicare and Medicaid Services | The Federal agency that administers the Medicare and Medicaid programs; CMS assists the WTC Health Program with payment functions |
| Centralized Accessible Real-time Enterprise Portal | A web application and portal managed by the Program that allows authorized staff (Program, the Contractor, CCEs/NPA, and other contractors) to perform work-related responsibilities such as enrolling members, reviewing certifications, and transferring members. The Program’s CARE Portal also provides a mechanism to securely share ePHI and PII in a manner that protects patient privacy and complies with HIPAA and Privacy Act requirements |
| Certification | A decision by the WTC Health Program that a member's health condition is included on the List of WTC-Related Health Conditions, that the health condition and 9/11 exposures meet Program policies, and that the member's exposure to airborne toxins, any other hazard, or any other adverse condition resulting from 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing the health condition. Certification authorizes a member's health condition to be eligible for treatment by the Program; Program members receive coverage only for services deemed medically necessary to treat certified conditions; Regulations: § 88.18 Certification. |
WTC-related health condition. The WTC Health Program will review each physician determination and render a decision regarding certification of the condition as a WTC-related health condition. The WTC Health Program will notify the WTC Health Program member of the decision and the reason for the decision in writing.
| Certification Redo | Certification status wherein a certification request is put in a suspended status upon determination that additional information is required prior to approval or denial. The certification remains in this suspended status until specific facts are either supplied (when missing) or clarified (when too vague or misleading) by the CCE/NPA submitting the certification request. If the additional information is not provided within 60 calendar days, the certification is administratively closed |
| Certified-Eligible Survivor | A Survivor with a certified WTC-related health condition(s). These members are eligible for annual monitoring exams and treatment for certified WTC-related and medically associated health condition(s) |
| Claim Review Form | A WTC Health Program form used to request a review of a claim or a claim appeal after the claim has been adjudicated |
| Clean Claim | A medical claim that is fully correct with zero mistakes and can be processed without additional information from the provider or a third party. According to CMS, a clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment |
| Clinical Center of Excellence | One of the Program's contractors, further described in Section 1.1 of the TPA PWS. There are currently 8 CCEs contracted with the Program |
| Clinical Services | Services that require a clinical staff member to complete. This may include services such as treatment, diagnostic, and intensive case management services |
| Close of Business | The end of the standard business day, 5pm Eastern |
| Comma-separated values | Text file format that uses commas to separate values (delimited text file) |
| Commercial Off-the-Shelf | Product (hardware or software) that is ready-made and adapted after purchase, rather than a commissioned and custom-made solution |
| Comprehensive Cost Avoidance, Coordination of Benefits & Recovery Contractor | One of the Program's contractors, further described in Section 1.1 of the TPA PWS |
| Concurrent Review (UM) | Method of reviewing patient care and services while care is being delivered or provided to validate the necessity of care and to explore alternatives for those receiving inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated. CCR involves review of necessity decisions made while the patient is currently in an acute, post-acute, or outpatient setting (CCR may also be referred to as “Urgent Concurrent”) |
| Confidential Information | Government information that is not or will not be generally available to the public |
| Continued Stay Review (UM) | Type of review used to determine if ongoing inpatient care is medically necessary or appropriate and that care is being rendered at the appropriate level. It takes place concurrently to a member's hospitalization for care, similar to CCR |
| Continuity of Operations | Effort to ensure that essential functions can be continued throughout--or resumed rapidly after--a disruption of normal activities due to a wide range of events or situations, including localized acts of nature, accidents, and technological emergencies |
| Contract Year | Year cycle based on the start date of the contract. A contract year does not necessarily follow the calendar year |
| Contractor Attributional/Proprietary Information | Information that identifies the contractor(s), whether directly or indirectly, by the grouping of information that can be traced back to the contractor(s) (e.g., program description, facility locations), personally identifiable information, as well as trade secrets, commercial or financial information, or other commercially sensitive information that is not customarily shared outside of the company |
| Contractor Performance Assessment Reporting System | System that allows government agencies to report and rate contractor performance |
| Controlled Unclassified Information | Information that law, regulation, or governmentwide policy requires to have safeguarding or disseminating controls, excluding information that is classified under Executive Order 13526, Classified National Security Information, December 29, 2009, or any predecessor or successor order, or the Atomic Energy Act of 1954, as amended |
| Coordination of Benefits | Process that allows plans that provide health and/or prescription coverage for a person to determine their respective payment responsibilities and the order of payment. Coordination of Benefits is required for WTC Health Program survivors pursuing treatment for WTC-related health conditions and health conditions medically associated with a WTC-related health condition, wherein the WTC Health Program survivor's public or private health insurance plan is the primary payer. The WTC Health Program will seek to coordinate benefits among all appropriate entities in the same manner and to the same extent as required by Section 1862(b) of the Social Security Act (Medicare as Secondary Payer) 42 USC 300mm-41(c)(1) and 42 USC 1395y(b)(2) for medical treatment claims (exclusions: initial health evaluations, monitoring, screening, and diagnostics). The WTC Health Program will pay costs not reimbursed by the public or private health insurance plan due to the application of deductibles, co-payments, co-insurance, other cost sharing arrangements, or payment caps up to and in accordance with the rates described in 42 CFR 88.22(b); Survivor: The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act), as amended, requires the World Trade Center (WTC) Health Program medical and pharmacy claims for Survivor members go through a process called Coordination of Benefits (COB). Pharmacy - For Survivors, Coordination of Benefits applies to prescription drug coverage for WTC-related health conditions the same as WTC-related medical care—the pharmacy must bill your primary insurance first, including any public insurance such as Medicare or Medicaid, and then bill the WTC Health Program any remaining amount. This leaves no cost to you. There are no copayments, coinsurance, or deductibles for WTC-related prescriptions covered by the Program; Coordination of Benefits: |
A process that helps determine who pays a medical bill first when there is more than one potential payer.
COB sets the order in which different payors (e.g., private insurance, public insurance, the WTC Health Program) pay their share of costs for treatment of a Survivor’s certified WTC-related health condition.
| Corrected Claim | A replacement of a previously submitted claim that requires a revision to coding, service dates, billed amounts, or member/provider information. A corrected claim is not an inquiry or appeal |
| Corrective Action Plan | Method of documenting approach to resolving issues, including root cause analysis and documentation of a solution that is measurable, achievable, and in a realistic timeframe. Corrective Action Plans may be requested by the CO when contractor performance does not conform with contractual requirements and performance standards |
| Covered Contractor Information System | An information system that is owned and operated by a contractor and all sub-contractors that processes, stores, or transmits Federal contract information. These systems are non-federal systems that store federal Controlled Unclassified Information (CUI) data |
| Covered Entity | (1) A health plan, (2) A health care clearinghouse, or (3) A health care provider who transmits any health information in electronic form in connection with a transaction covered by 45 CFR 160. In reference to this contract, the covered entity is the WTC Health Program |
| Crosswalk | Process for transforming/combining data elements from different systems to enable standardized usage of information in a single platform/analysis tool; Identifying corresponding data elements across different data systems/sources/files/etc. or to data elements/naming conventions that have changed over time. The reference document that describes the relationship between the two systems is also called a crosswalk |
| Current Procedural Terminology | Set of standardized procedural codes for classifying medical services and procedures maintained by the American Medical Association (AMA) |
| Cyber Incident | Actions taken through the use of computer networks that result in a compromise or an actual or potentially adverse effect on an information system and/or the information residing therein |
| Dashboard | The user interface of a data visualization tool/platform that has been built for a specific purpose and includes interactive filtering capabilities; the data feeds informing the visualizations should be updated at a specified frequency while the main format/structure remains consistent |
| Data Availability | Property that data or information is accessible and usable upon demand by an authorized person |
| Data Center | One of the Program's contractors, further described in Section 1.1 of the TPA PWS. There are currently 3 DCs contracted with the Program |
| Data Confidentiality | Property that data or information is not made available or disclosed to unauthorized persons or processes, including means for protecting personal privacy and proprietary information |
| Data Exchange | The process of taking data structured under a source schema and transforming it into a target schema, so that the target data is an accurate representation of the source data |
| Data Extract | Line-level dataset that may include only selected columns/fields but has not undergone extensive transformations, manipulations, or analysis. Data can be raw or cleaned, and is typically delivered on a set cadence |
| Data Flow Diagram | Reference tool that shows all data elements that are moving in and out of a system. The diagram should show the exchange partner(s), direction of flow, and other details as possible. Data Flow Diagrams can cover a multitude of sizes spanning an overarching view of an entire unit or just a basic flow of a specific system |
| Data Integrity | Property that data is accurate, complete, and of high quality as it is maintained over time, across formats and systems, and the property that data has not been modified or destroyed in an unauthorized manner. Data integrity covers data in storage, during processing, and while in transit |
| Data Management Plan | Document that describes the collection, protection, processing, analysis, public sharing, and long-term preservation of public health data—or contains a justification for not sharing/preserving |
| Data Recoverability | Property where data or information is stored in a way that lost, corrupted, accidentally deleted, or otherwise inaccessible data can be successfully restored |
| Data Use Agreement | A required legal agreement that must be executed before there is any use, exchange, transfer, sharing, or disclosure of one or more limited or restricted datasets between the agreement parties. CDC data might be restricted because it is protected by a contract, agreement, or privacy law such as the Privacy Act. CDC may also share or receive a limited dataset from a HIPAA covered entity, which is still PHI. Covered entities, including the health care component of CDC, must have a data use agreement with any limited dataset recipient or provider |
| Date of Service | The date on which a medical service/treatment was performed, as opposed to the billing or claim submission dates |
| Death Master File | Data sourced from the Social Security Administration (SSA) that contains information about deceased persons, including decedent name, date of birth, date of death, and Social Security Number. Can be used to verify vital statistics for Program members |
| Defer (Enrollment) | Enrollment decision, applicable to survivor applicants only, where the Program has made a determination that the individual has successfully demonstrated that they meet exposure criteria for enrollment, but has not reported current health symptoms |
| Designated Representative | A single individual selected by an applicant, WTC responder, or a screening-eligible or certified-eligible survivor to represent their administrative interests to the Program. Designated Representatives may only receive PHI from the Program in accordance with a signed HIPAA Authorization provided by the applicant/member |
| Diagnostic Codebook | A list of medical codes managed by the Program that determines approved medical conditions covered by the Program (including Related Conditions, Medically Associated Conditions, and Ancillary Conditions), identifies care suites, and other applicable coverage guidelines. The codebook is maintained to align with the current revision of ICD-10; however, Program certifications are a snapshot in time and are currently both in ICD-9 and ICD-10 formats depending on the date of certification |
| Disclosure (of PII/PHI) | The release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information |
| Disenrollment | Process of terminating membership for a WTC Health Program member, which can occur if (1) the WTC Health Program mistakenly enrolled an individual who did not provide sufficient proof of eligibility consistent with the required eligibility criteria, or (2) the WTC Health Program member's enrollment was based on incorrect or fraudulent information. A disenrolled member will be notified in writing by the WTC Health Program of a disenrollment decision and provided information on how to appeal the decision |
| Dual Operations | Contract phase (during Transition-In and Transition-Out) wherein the incoming and incumbent contractors are both handling operations for potentially the same services. Examples may include; claims, call center operations, reporting to the WTC Health Program, member certifications, member enrollments, etc. |
| Edge Case | A scenario that affects only a subset of people or can only be reproduced under uncommon circumstances, outside of normal operating parameters |
| Electronic Data Interchange | Concept of communicating information electronically using a standardized format, used as a secure way of transmitting data; an example is the EDI 837 transaction for submitting healthcare claim and encounter information. EDI provides a mechanism for medical claims to be transmitted electronically from the CCEs/NPA, NYMA EPN, and NPN to the TPA Contractor |
| Electronic File Transfer | Process that uses an electronic format and protocol to exchange data files securely, such as the secure file transfer protocol (SFTP) |
| Electronic Funds Transfer | Process of transferring money electronically from one bank account to another; the Program's providers are required to enroll in EFT per Section 1104 of the ACA |
| Electronic Protected Health Information | Protected health information transmitted by electronic media or maintained in electronic media |
| Enrollment | A determination by the Program that an applicant is eligible as one of the four groups served by the Program (FDNY responders, WTC general responders, WTC survivors, Pentagon/Shanksville responders) and that their reported 9/11 exposure meets criteria for the activity, location, duration, time period and, if applicable, qualifying symptoms of a WTC-related condition as outlined in the Zadroga Act. An approved enrollment entitles a new member to medical monitoring (See Initial Health Evaluation/first Annual Monitoring Exam) |
| Explanation of Benefits | Document that explains to a member how claims were processed for the services rendered; An Explanation of Benefits is a statement from your primary insurance company that details what a medical service cost, what they paid, and what is left over. IT IS NOT A BILL. It will often say that somewhere on it. It breaks down the cost of the medical services. It might also show a balance remaining. It might even say something like “your responsibility” or “patient’s responsibility.” Because it can look like a bill, this can be very confusing. For WTC-related claims for approved services, remember that you are not responsible for the remaining amount shown on an Explanation of Benefits or a bill. The Program pays that remaining cost |
| External Provider Network | A facility, health care professional, or other person or entity, including Providers throughout the NYMA that do not operate within the CCE. These Providers will have entered into an agreement directly with the Program to abide by the Program's Terms and Conditions to provide medical services to WTC Health Program designated members. This network is currently managed by the Health Program Support Contractor and will be managed by the Third-Party Administrator with this contract transition |
| External Standard Operating Procedure | Document written by the WTC Health Program for a contract vendor(s) on how to carry out a process required in the contract. The XP is used sparingly as the Government generally defers to the Contractor on how contractual tasks are completed; however, in some cases to standardize operations across vendors or to detail when and how to use Program systems, the XP is utilized. XPs do not replace a Contractor's Ops Manual and internal SOPs |
| Federal Information Processing Standards | Standard for adoption and use by federal departments and agencies that has been developed within the Information Technology Laboratory and published by the National Institute of Standards and Technology, a part of the U.S. Department of Commerce. A FIPS covers some topic in information technology in order to achieve a common level of quality or some level of interoperability |
| Federal Information Security Management Act of 2002 | FISMA defines a framework of guidelines and security standards to protect government information and operations. FISMA requires all federal agencies to develop, document and implement agency-wide information security programs |
| Federal Record | All recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them. The term Federal record: 1) includes Centers for Disease Control and Prevention (CDC) records, 2) does not include personal materials, 3) applies to records created, received, or maintained by Contractors pursuant to their CDC contract, and 4) may include deliverables and documentation associated with deliverables |
| Fee for Service | Reimbursement model in which health care providers are paid for each service performed |
| Fire Department of the City of New York | One of the vendors who is currently contracted to the Program as a CCE and as a DC |
| Fiscal Year | A year cycle based on the federal government's fiscal year, starting October 1 and ending September 30 of the following calendar year |
| Forensic Analysis | The practice of gathering, retaining, and analyzing computer-related data for investigative purposes in a manner that maintains the integrity of the data |
| Formulary | List of pharmaceutical drugs that are covered by the Program, as well as criteria that must be met prior to the prescription being approved through the Program |
| Fraud (FWA) | An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Examples include 1) providing false statements on an enrollment application to obtain coverage or concealing information about past medical history/preexisting conditions; 2) knowingly soliciting, receiving, offering, or paying renumeration to induce or reward referrals for items of services reimbursed by the Program; and 3) billing for services that were not rendered or providing services that are not medically necessary |
| General Dynamics Information Technology, Inc. | One of the vendors currently subcontracted to the Program under the HPS Contractor (Karna) |
| Health Care | Care, services, or supplies related to the health of an individual. Health care includes, but is not limited to, the following: 1) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and 2) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription |
| Health Condition Medically Associated with a WTC-Related Health Condition | A condition that results from the treatment or progression of a certified WTC-related health condition. “Results from” means that the relationship linking the medically associated health condition with the WTC-related health condition occurs without the influence of an intermediary health condition or event, and that the linkage has been well-established by published, peer-reviewed scientific literature. Once certified, health conditions medically associated with a WTC-Related health condition are eligible for treatment covered by the Program |
| Health Information | Any information, including genetic information, whether oral or recorded in any form or medium, that: 1) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and 2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual |
| Health Maintenance Organization | A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO |
| Health Program Evaluation Contractor | One of the Program's contractors, further described in Section 1.1 of the TPA PWS |
| Health Program Support Contractor | One of the Program's contractors, further described in Section 1.1 of the TPA PWS |
| Health Research and Analysis, LLC | The vendor currently contracted to the Program as the HPE Contractor |
| Healthcare Common Procedure Coding System | Set of standardized procedural codes for classifying medical procedures, supplies, products, and services maintained by CMS based on CPT |
| Homeland Security Presidential Directive-12 | Policy that calls for a mandatory, government-wide standard for secure and reliable identification for all of its employees and employees of federal contractors to access federally-controlled facilities and networks. Often used to reference Personal Identity Verification (PIV) cards that meet this policy |
| HTTP Strict Transport Security | A simple and widely supported standard to protect visitors by ensuring that their browsers always connect to a website over HTTPS. HSTS exists to remove the need for the common, insecure practice of redirecting users from http:// to https:// URLs |
| Hypertext Transfer Protocol Secure | The secure version of HTTP, which is the primary protocol used to send data between a web browser and a website. HTTPS is encrypted in order to increase security of data transfer |
| Icahn School of Medicine at Mount Sinai (formerly Mount Sinai School of Medicine) | One of the vendors who is currently contracted to the Program as a CCE |
| Inactive (Enrollment) | Enrollment status wherein an incomplete enrollment application is no longer actively being "worked" by the Program. As opposed to the suspend status, where applicants are contacted on a regular cadence to provide additional information, applicants in inactive only receive one annual letter reminding them that the Program is still in need of additional information prior to an enrollment decision being rendered |
| Individually Identifiable Health Information | Information that is a subset of health information, including demographic information collected from an individual, and: 1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and 2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and i) That identifies the individual; or ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual |
| Information Security Officer | Individual who monitors the organization's IT system to look for threats to security, establish protocols for identifying and neutralizing threats, and maintain updated anti-virus software to block threats |
| Information Systems Security Officer | Individual who plans, implements, upgrades, or monitors security measures for the protection of computer networks and information. An ISSO also assesses system vulnerabilities for security risks and proposes and implement risk mitigation strategies |
| Information Technology | Information technology is a set of related fields that encompass computer systems, software, programming languages and data and information processing and storage. IT forms part of information and communications technology |
| Initial Health Evaluation / First Annual Monitoring Exam | Baseline (initial) assessment of one or more symptoms that may be associated with a WTC-related health condition and includes a medical, occupational, and exposure history, a physical examination, and additional medical testing as needed to evaluate whether the individual has a WTC-related health condition or health condition medically associated to a certified WTC-related health condition and is eligible for treatment under the WTC Health Program |
For screening-eligible survivors, the Initial Health Evaluation is a one-time evaluation used to determine whether the member is eligible for follow-up monitoring (AME) and treatment benefits, though survivors may seek additional screenings at their own expense. For responders who are inherently eligible for follow-up monitoring, this baseline assessment is just the first AME. For simplicity, these exams are often referred to collectively as the first visit or "V1"; Initial Health Evaluation:
Also called a baseline monitoring exam for Responders; Assessment of one or more symptoms that may be associated with a WTC-related health condition to evaluate whether a new member has a WTC-related health condition and is eligible for treatment under the Program. This exam includes a medical and exposure history, a physical examination, and additional medical testing as needed.
| In-Network Provider | A facility, health care professional, or other person or entity, including Provider, that has satisfied all applicable credentialing Policies or Procedures to have a contract to be in the WTC Health Program External Provider Network or Nationwide Provider Network, agreeing to provide health care services in accordance with Program terms and conditions. |
| Interconnection Security Agreement | A document that regulates security-relevant aspects of an intended connection between an agency and an external system. It regulates the security interface between any two systems operating under two different distinct authorities. It includes a variety of descriptive, technical, procedural, and planning information. It is usually preceded by a formal MOA/MOU that defines high-level roles and responsibilities in management of a cross-domain connection |
| International Classification of Diseases | System of diagnostic codes for classifying diseases maintained by the World Health Organization (WHO). The Program maintains a diagnostic codebook that lists all conditions covered by the WTC Health Program, including Related Conditions, Medically Associated Conditions, and Ancillary Conditions. The codebook is maintained to align with the current revision of ICD-10; however, Program certifications are a snapshot in time and are currently both in ICD-9 and ICD-10 formats depending on the date of certification |
| Letter of Agreement | Legal document that establishes a relationship between a provider and a health plan (in this case, the Program) to allow services to be provided to a group of members at an agreed-upon rate without the provider being considered an in-network provider. LOAs may be used to initiate services while credentialing is in progress, prior to a confirmed enrollment. An LOA is only considered executed once the provider (or an authorized representative of the participating organization) has duly signed the agreement and the agreement is returned to the provider with written notice that indicates the dates on which it was signed by the provider's representative and accepted by the Program. |
| Limited Benefit Health Plan | A health plan that only covers a specific and restricted set of treatments, services, and supplies for a specific and restricted set of conditions. The Program’s limited health benefit program covers limited medically necessary services to diagnose, monitor, and/or treat qualifying conditions. For example, treatment is only covered for specific covered health condition(s) for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks has been determined to be substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition in an individual member |
| List of WTC-Related Health Conditions | List of conditions determined to be related to 9/11 exposure, per 42 CFR 88.15 |
| Lost to Follow-Up | Applicant/member status wherein it is determined that the applicant/member has no valid phone numbers, email addresses, and/or mailing addresses on file. This means that the Program has no possible way to contact the individual based on the information available in the individual's Program record |
| Managed Care Advisors-Sedgwick | The vendor currently contracted to the Program as the NPN Contractor, administering the Nationwide Provider Network and serving as the National Program Administrator, managing Program health care for members who live outside of the NY metropolitan area. Sedgwick is MCA's parent company. |
| Maximum Time Interval | The amount of time between the last date of an individual's 9/11 exposure and the onset of symptoms of the individual's aerodigestive disorder. Maximum time interval requirements must be met in order for certain aerodigestive disorders to be certified by the Program |
| Medical Benefits | Services of physicians and other healthcare providers, diagnostic and laboratory tests, prescription drugs, inpatient and outpatient hospital services, and other medically necessary treatment |
| Medical Coverage Determination | An administrative tool which provides coverage information for specific services, along with qualifying criteria for coverage, and instructions for authorization |
| Medical History Questionnaire | Term used to describe the standard questions to obtain medical, occupational, and exposure history during the Initial Health Evaluation/first Annual Monitoring Exam |
| Medical Monitoring | Periodic physical and mental health assessment of a WTC responder or certified-eligible survivor in relation to exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks and which includes a medical and exposure history, a physical examination and additional medical testing as needed for surveillance or to evaluate symptom(s) to determine whether the individual has a WTC-related health condition. Generally, a WTC responder or certified-eligible survivor receives annual physical and mental health assessments. |
Medical monitoring is used to identify health concerns for early intervention, characterize the health of Program mebers over time, facilitate efforts for continuous quality improvement in the healthcare rendered by the Program, and informs emergency preparedness efforts for future disasters
| Medical Monitoring and Treatment Program | Precursor federal program established in 2006 to provide diagnostic and treatment services for WTC-related occupational health conditions. The WTC Health Program replaced the MMTP in July 2011 |
| Medical Policy | Set of documents that establish guidelines for determining what medical services, procedures, and supplies are medically necessary for the treatment or monitoring of qualifying conditions and therefore eligible for coverage. Medical policy is grounded in the best and most current scientific evidence and is updated to reflect changes in such evidence. For the purposes of the Program, medical policy indicates what services shall be covered for each of the Program’s qualifying WTC-related conditions, health conditions medically associated with a WTC- related condition, and ancillary conditions. Medical policy may be housed in the Program’s codebook, public website, Administrative Manual, and other related Program documents |
| Medically Necessary Treatment | Services provided by physicians and other health care providers to a WTC Health Program member, including diagnostic and laboratory tests, prescription drugs, inpatient and outpatient hospital services, and other care that is appropriate, to manage, ameliorate, or cure a WTC-related health condition or a health condition medically associated with a WTC-related health condition, and which conforms to medical treatment protocols and guidelines developed by the Program and/or by Data Centers, with input from the CCEs, and approved by the Administrator of the WTC Health Program |
| Medically Unlikely Edits | The maximum units of service that a provider would report under most circumstances for a single member on a single date of service. Not all procedure codes have an MUE |
| Medicare Provider Enrollment, Chain, and Ownership System | The online Medicare enrollment management system which allows an individual to enroll as a Medicare provider or supplier, renew enrollment, review and update information, report changes to the enrollment record, and electronically sign and submit information. The WTC Health Program leverages this system for WTC Health Program provider enrollment as well |
| Member | A responder, screening-eligible survivor, or certified-eligible survivor enrolled in the WTC Health Program |
| Member Services | Functional area that includes all applicant and member-facing operations provided by the Contractor to include operations support for enrollment, certification, clinic transfer, appeals, Designated Representative processing, mail center administration, customer service (including operation of a call center and self-service portal), and management and maintenance of the member profile (including demographics, OHI information, and formulary management) |
| Mental Health Conditions | One of the five Zadroga Condition Categories; conditions that affect an individual's mood, thinking, and behavior |
| Minimum Essential Coverage | Any insurance plan that meets the Affordable Care Act requirement for having health coverage. All members with certified WTC-related health condition(s) or a health condition(s) medically associated with a WTC-related health condition which are not work-related are required to have minimum essential health insurance coverage at the time the claimed treatment services were rendered or must be identified as exempt from having minimal essential coverage; All members are responsible for maintaining minimum essential coverage (primary health insurance requirement). For Survivors, treatment benefits under the Program will be coordinated with their primary health insurance plan and the Program. |
| Minimum Necessary | HIPAA standard requiring a covered entity (i.e., the Program) or business associate (i.e., the Contractor) to make reasonable efforts to limit PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure or request when using or disclosing PHI or requesting PHI from another covered entity or business associate |
| Musculoskeletal Disorders | One of the five Zadroga Condition Categories; chronic or recurring disorders of the musculoskeletal system caused by heavy lifting or repetitive strain on the joints. The Program covers musculoskeletal disorders for Responders only |
| National Government Services | The vendor who is currently contracted to CMS as its payment contractor. The TPA Contractor will send payment files to NGS, who then processes the data through established channels at CMS to send a payment file to the Treasury Department, which issues EFT payments to WTC Health Program providers |
| National Plan & Provider Enumeration System | Registry system created by CMS that issues National Provider Identifiers (NPIs) to covered health care providers and entities |
| National Program Administrator | One of the Program's contractors, further described in Section 1.1 of the TPA PWS |
| National Provider Identifier | A unique identification number for covered health care providers issued through NPPES |
| Nationwide Provider Network | A nationwide network of health care providers across the country under contract with the Program to provide WTC-related health care for Program members who live outside the NY metropolitan area and want to receive their WTC-related health care locally |
| Negative Determination | A finding that exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, attacks, is not substantially likely to be a significant factor in aggravating, contributing to, or causing the health condition or mental health condition. A certification request with a negative physician determination cannot be submitted to the Program for decision |
| New York City Disaster Area | An area within New York City that is the area of Manhattan that is south of Houston Street and any block in Brooklyn that is wholly or partially contained within a 1.5-mile radius of the former World Trade Center complex |
| New York City Health + Hospitals |
World Trade Center Environmental Health Center
| (formerly Health + Hospitals Corporation) | One of the vendors who is currently contracted to the Program as a CCE and as a DC | |
| New York Committee for Occupational Safety and Health | One of the vendors who is currently contracted to the Program as an O&E Contractor | |
| New York Metropolitan Area | New York metropolitan area means the combined statistical areas comprising the Bridgeport-Stamford Norwalk, CT Metropolitan Statistical Area; Kingston, NY Metropolitan Statistical Area; New Haven-Milford, CT Metropolitan Statistical Area; New York-Northern New Jersey-Long Island, NY-NJ-PA Metropolitan Statistical Area; Poughkeepsie-Newburgh-Middletown, NY Metropolitan Statistical Area; Torrington, CT Micropolitan Statistical Area; Trenton-Ewing, NJ Metropolitan Statistical Area. This aligns with the Zadroga Act definition of "an area, specified by the WTC Program Administrator, within which WTC responders and eligible WTC screening eligible survivors who reside in such area are reasonably able to access monitoring and treatment benefits and initial health evaluation benefits under this title through a Clinical Center of Excellence described in subparagraphs (A), (B), or (C) of section 3305(b)(1)" | |
| New York University Grossman School of Medicine | One of the vendors who is currently contracted to the Program as a CCE | |
| NIOSH Office of the Director of Information Technology | CDC/NIOSH office that provides centralized NIOSH IT services to enable divisions and branches to focus on science and informatics while offloading IT management, governance, security and compliance requirements | |
| Non-Clinical Services | Non-clinical services may include services such as benefits counseling, social services, and member services. Non-clinical services do not require a clinical staff member to complete them | |
| Northwell Health | One of the vendors who is currently contracted to the Program as a CCE | |
| Notice of Participation | Sworn statement indicating the dates and locations of participation in WTC rescue, recovery, and clean-up operations. The NOP is a form created by New York State required to be submitted to preserve the individual's right to apply for disability retirement in New York under the WTC Disability Law. NOPs are one of the more common document types submitted as supporting documentation for a WTC Health Program enrollment application | |
| Notice of Privacy Practices | Document that explains how a covered entity can use or disclose an individual's PHI. The Program's NOPP can be found online at https://www.cdc.gov/wtc/privacy.html |
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