Chapter 4

Question 1

Title XVIII

Answer 1

Medicare

Question 2

SSA

Answer 2

Social Security Act

Question 3

Who is eligible for Title XVIII?

Answer 3

Individuals with a permanent disabilities, age 65 and older, ESRD, or Lou Gehrig’s Disease

Question 4

ESRD

Answer 4

End Stage Renal Disease

Question 5

Beneficiary

Answer 5

Person who is eligible and entitled to Medicare benefits.

Question 6

Medicare part A

Answer 6

Covers Inpatient, SNF, and Hospice

Question 7

Benefit period

Answer 7

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.

Question 8

Deductible

Answer 8

Amount a patient is responsible for before their benefits start.

Question 9

2019 Medicare Part A deductible

Answer 9

$1364.00 per spell

Question 10

Medicare part B

Answer 10

Covers outpatient hospital care, office visits, some services Medicare part A will not cover

Question 11

2019 Medicare part B deductible

Answer 11

$185.00 per year

Question 12

Medicare part B coinsurance

Answer 12

20% of Medicare- approved amount

Question 13

Medicare Advantage or Replacement plan

Answer 13

Medicare part C

Question 14

Health Maintenance Organization (HMO)

Answer 14

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.

Question 15

Preferred Provider Organization (PPO)

Answer 15

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.

Question 16

Medicare Prescription Plan

Answer 16

Medicare Part D

Question 17

Formulary

Answer 17

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.

Question 18

MAC’s

Answer 18

Medicare Administrative Contractors

Question 19

Medigap

Answer 19

Medicare supplemental Insurance ( ONLY works with the original Medicare policy)

Question 20

Title XIX (19)

Answer 20

Medicaid

Question 21

Medicaid

Answer 21

Federal government and state funded

Question 22

Dual Coverage

Answer 22

Beneficiaries who are eligible for both Medicare and Medicaid benefits

Question 23

Worker’s Compensation

Answer 23

A worker who is injured while performing their job

Question 24

NAS

Answer 24

Non- Availability Statement

Question 25

Tricare

Answer 25

TRICARE is the health care program for uniformed service members, retirees, and their families around the world.

Question 26

CHIP

Answer 26

Children’s Health Insurance Program

Question 27

Title XXI

Answer 27

Children’s Health Insurance Program

Question 28

Program administered by the state for families who do not qualify for Medicaid but can not afford private insruance

Answer 28

CHIP

Question 29

Self-Insured

Answer 29

do not purchase group insurance but put the premiums into a fund to cover services

Question 30

HSA

Answer 30

Health Savings Accounts

Question 31

Health Savings Accounts

Answer 31

Bank accounts maintained by the patients to pay medical expenses for high Deductible health plans (pre taxed dollars)

Question 32

COB

Answer 32

Coordination of Benefits

Question 33

Payer of last resort

Answer 33

Medicaid

Question 34

Birthday Rule

Answer 34

determines COB for a child who is covered by both parents. The parent with the first birthday in the calendar year

Question 35

Conditional Payment

Answer 35

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

Question 36

POA (I)

Answer 36

Present on admission Indicators

Question 37

NDC

Answer 37

National Drug Code

Question 38

APC

Answer 38

Ambulatory payment Classification

Question 39

MAAC

Answer 39

maximum allowable actual charge

Question 40

RVU

Answer 40

relative value unit

Question 41

MVPS

Answer 41

Medicare Volume Performance Standard

Question 42

PE

Answer 42

Practice Expense

Question 43

MP

Answer 43

Malpractice insurance expense

Question 44

UCR

Answer 44

Usual, Customary, and Reasonable

Question 45

Usual, Customary, and Reasonable

Answer 45

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.

Question 46

PPS

Answer 46

Prospective Payment System

Question 47

CAH

Answer 47

Critical Access Hospital

Question 48

Capitation

Answer 48

Method of payment in which a provider is paid a SET dollar amount for each patient for a specific time period

Question 49

Per Diem

Answer 49

method of payment providers are paid a predetermined amount for each day an Inpatient

Question 50

Chargemaster

Answer 50

an electronic file that contains charges that can be posted to patients account

Question 51

Locum Tenens

Answer 51

is a temporary substitute for the Dr of a member of the clergy

Question 52

Self-pay (SP)

Answer 52

Patients who do not have any insurance to bill. Providers can ask for money owed for services prior to the provider seeing the patient.

Question 53

MSN

Answer 53

Medicare Summary Notice

Question 54

Medicare Summary Notice

Answer 54

A notice beneficiaries using traditional Medicare insurance will receive every 3 months (quarterly) showing all Part A and Part B covered services.

Question 55

RA

Answer 55

Remittance Advice

Question 56

EOB

Answer 56

Explanation of Benefits

Question 57

Medicare Timely Filing

Answer 57

claims must be submitted within 12 months from DOS

Question 58

MUE

Answer 58

Medically Unlikely Edits

Question 59

MCE

Answer 59

Medicare Code Editor

Question 60

Clean Claims

Answer 60

Claim that does not require the carrier to investigate

Question 61

Non- Standard claim

Answer 61

claim that has attachments in lieu of data entered correctly on the form