Chapter 4 Flashcards
Title XVIII
Medicare
SSA
Social Security Act
Who is eligible for Title XVIII?
Individuals with a permanent disabilities, age 65 and older, ESRD, or Lou Gehrig’s Disease
ESRD
End Stage Renal Disease
Beneficiary
Person who is eligible and entitled to Medicare benefits.
Medicare part A
Covers Inpatient, SNF, and Hospice
Benefit period
A benefit period is the way the original Medicare program measures a beneficiaries use of inpatient hospital and skilled nursing facility services. It begins the day a beneficiary enters the hospital or SNF and ends when when no further inpatient or SNF services have been rendered for 60 days in a row. The benefit period is not tied to the calendar year. This can also be a term used to describe a length of time during which a benefit is paid.
Deductible
Amount a patient is responsible for before their benefits start.
2019 Medicare Part A deductible
$1364.00 per spell
Medicare part B
Covers outpatient hospital care, office visits, some services Medicare part A will not cover
2019 Medicare part B deductible
$185.00 per year
Medicare part B coinsurance
20% of Medicare- approved amount
Medicare Advantage or Replacement plan
Medicare part C
Health Maintenance Organization (HMO)
Type of health insurance plan that usually limits coverage to care from a doctor or group of doctors who are contracted with the HMO. It generally won’t cover out-of-network care except in an emergency. HMO’s have the most restricted coverage area - a very small group of providers to choose from.
Preferred Provider Organization (PPO)
Similar to an HMO where a patient can receive healthcare from providers within an established network set up by an insurance company, but is not as restrictive as an HMO - a larger group of providers to choose from.
Medicare Prescription Plan
Medicare Part D
Formulary
A drug formulary is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. A committee of independent, actively practicing physicians and pharmacists maintain the formulary list.
MAC’s
Medicare Administrative Contractors
Medigap
Medicare supplemental Insurance ( ONLY works with the original Medicare policy)
Title XIX (19)
Medicaid
Medicaid
Federal government and state funded
Dual Coverage
Beneficiaries who are eligible for both Medicare and Medicaid benefits
Worker’s Compensation
A worker who is injured while performing their job
NAS
Non- Availability Statement
Tricare
TRICARE is the health care program for uniformed service members, retirees, and their families around the world.
CHIP
Children’s Health Insurance Program
Title XXI
Children’s Health Insurance Program
Program administered by the state for families who do not qualify for Medicaid but can not afford private insruance
CHIP
Self-Insured
do not purchase group insurance but put the premiums into a fund to cover services
HSA
Health Savings Accounts
Health Savings Accounts
Bank accounts maintained by the patients to pay medical expenses for high Deductible health plans (pre taxed dollars)
COB
Coordination of Benefits
Payer of last resort
Medicaid
Birthday Rule
determines COB for a child who is covered by both parents. The parent with the first birthday in the calendar year
Conditional Payment
when another payer (liability carriers ) is to be responsible for the claim but the claim is not expected to be paid within 120 days. Medicare will make a payment to prevent the patient from paying out of pocket
POA (I)
Present on admission Indicators
NDC
National Drug Code
APC
Ambulatory payment Classification
MAAC
maximum allowable actual charge
RVU
relative value unit
MVPS
Medicare Volume Performance Standard
PE
Practice Expense
MP
Malpractice insurance expense
UCR
Usual, Customary, and Reasonable
Usual, Customary, and Reasonable
Amount paid for a medical service in a geographical area based on what providers in the area usually charge for the same or similar medical service. This amount is sometimes used to determine the allowed amount by insurance companies.
PPS
Prospective Payment System
CAH
Critical Access Hospital
Capitation
Method of payment in which a provider is paid a SET dollar amount for each patient for a specific time period
Per Diem
method of payment providers are paid a predetermined amount for each day an Inpatient
Chargemaster
an electronic file that contains charges that can be posted to patients account
Locum Tenens
is a temporary substitute for the Dr of a member of the clergy
Self-pay (SP)
Patients who do not have any insurance to bill. Providers can ask for money owed for services prior to the provider seeing the patient.
MSN
Medicare Summary Notice
Medicare Summary Notice
A notice beneficiaries using traditional Medicare insurance will receive every 3 months (quarterly) showing all Part A and Part B covered services.
RA
Remittance Advice
EOB
Explanation of Benefits
Medicare Timely Filing
claims must be submitted within 12 months from DOS
MUE
Medically Unlikely Edits
MCE
Medicare Code Editor
Clean Claims
Claim that does not require the carrier to investigate
Non- Standard claim
claim that has attachments in lieu of data entered correctly on the form
