Billing Flashcards
Title XVIII of the Social Security Act (SSA) is also known as…..
Medicare
The 4 qualifiers for Medicare are….
-elderly (65+)
-permanent disability
-end stage renal disease (ESRD)
-Lou Gehrig’s disease
I’m The 4 parts of Medicare are…
Part A
Part B
Part C
Part D
MDCR Part A covers_______
MDCR Part B covers_______
MDCR Part C covers_______
MDCR Part D covers_______
A - Inpatient hospital stays
B - Medical (review chart)
C - advantage or replacement
D - Drugs
5 types of Medicare Advantage plans
- Health Maintenance Organizations (HMO)
- Preferred Provider Organizations (PPO)
- Private Fee-for-service plans
- Special needs plans
- Medical Savings Accounts (MSAs)
MDCR advantage plan in which members must generally get healthcare from providers in the plan’s network is aka ______
HMO
MDCR advantage plan in which members can see any doctor or provider that accepts Medicare and don’t need a referral for specialist is aka______
PPO
MDCR advantage plan that allows members to go to any provider that accepts the plans terms is aka _______
Fee-for-service
MDCR advantage plan, which are limited to people in long-term care facilities (that are eligible for MDCR) and is only available in limited areas is aka _____
Special needs plans
MDCR advantage plan with two parts, a high deductible, plan, and an account Medicare deposits, money into is aka _______
Medical Savings Accounts (MSAs)
What is a formulary?
A list of medicare cover drugs
Private firms that process Medicare claims, enroll providers, provide education on billing requests, and answer provider and patient questions are also aka _____
Medicare administrative contractor (MAC)
DME stands for_______
Durable medical equipment
What are the advantages of the Medicare participating physician program?
-higher fee schedule payments
-fewer collection efforts
-publicity
-Government approval to display Medicare emblems
Are workers compensation regulations determined by the state or federal government?
State
Who is eligible for Tricare? What is the exception?
-active duty, spouses, dependents, and retirees (unless they are Medicare eligible)
The military member eligible for Medicare is called the ____
Sponsor
Under Tricare, when does the sponsor become eligible for benefits? What about other members?
-sponsor - on the first day of active orders
-others - after sponsor has been in active duty for 30 days
The Tricare supplement to Medicare is called ________
Tricare for Life
What is a NAS and when is is required?
Non-availability Statement. It’s required before non emergent inpatient services at a non-military treatment facility.
Title XXI of the Social Security Act is aka ________
CHIP - Children’s Health Insurance Program
Who qualifies for CHIP and are the standards set by state or federal governments?
Is the program state or federally funded?
Children, whose families fail to qualify for Medicaid but cannot afford private insurance.
The states design the eligibility standards
It is jointly funded by state and federal governments
Individual policies purchased by people who do not get insurance through an employer, are aka ____
Commercial Insurance Policies
Medicare is secondary to…..(6)
-employer coverage (either patients or spouses extended coverage)
-work comp
-black link coverage
-auto
-liability
-VA*
If a patient’s coverage changes to a Medicare HMO in the middle of an inpatient stay, is Medicare or the HMO responsible?
Medicare
TRICARE is the last payer after other health plans except ______
Medicaid
When is the VA primary to Medicare and vice versa?
The patient can choose the VA over Medicare, but must bill VA first. If patient chooses Medicare over, VA claim must be submitted to Medicare as primary and not submitted to the VA.
If Medicare is primary, no payment will be made by the VA
Does liability and property casualty insurance fall as primary or secondary most of the time?
Primary
Define the following HIPPA standard transportations
1. 835
2. 837 I/P
3. 279
4. 271
5. 267
6. 277
- 835 - healthcare payment remittance
- 837 I/P - institutional or professional claim file
- 270 - healthcare eligibility inquiry
- 271 - healthcare eligibility response.
- 267 - healthcare claim status inquiry.
- 277 - healthcare claim status response.
When do you use the following?
-ICD 10
-POA
-CPT 4
-HCPCS
-ICD 10 - diagnosis an inpatient procedures
-POA - inpatient claims
-CPT 4 - outpatient procedures
-HCPCS - outpatient procedures
What does AAHAM stand for?
American Association Healthcare Administrative Managment
The two federal agencies governing healthcare change are CMS and OIG. What to those acronyms stand for?
CMS - Center for MDCR/MDCD Services
OIG - Office of Inspector General
