Section 2 - Pre-Service Flashcards

1
Q

2.2. Order Requirements

Authenticate verbal order by physician written signature.
Qualified person must take verbal order
Waived for immunizations, screening mammography.

A

What Medicare requires in an order:

Patients full legal name
Date order written
Test ordered
Diagnosis - code or narrative
Name of ordering
Signature of ordering
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2
Q

2.2. Medical Necessity Screening and ABN

Pay if “reasonable and necessary”. 
Medicare guidelines (Local Coverage Determinations (LCD), National Coverage Determinations (NCD)) - determine which diagnoses, signs or symptoms are payable.
A

As participating provider in Health Plan, provider may have to provide similar form to ABN and document that informed patient service not likely to be covered.

Generic, routine and blanket ABN is not acceptable unless in cases such as freq limitations that apply to all patients.

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3
Q

2.2. When is ABN Needed?

Not if service is excluded.
Items and services expected to be denied.
Presumed to be Medicare benefit.

ABN can be used in place of Notice of Exclusion for Medicare Benefits (NEMB).
Reasons why inpatient may not be covered:
Medically unnecessary
Not delivered in most appropriate setting
Custodial

A

Providers should SPLIT CLAIMS so that one of 3 conditions holds for a single claim.

Patient selects one of 3 options on the form
Must give copy to the patient
Must keep signed copy
Patient cannot be billed if provide fails to provide an ABN

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4
Q

2.3. Pre-Registration

BP - 98% scheduled patients pre-registered.
Benefits:
Demo
Insurance
MSP screening
Medical necessity screening
Prior auth
Managed care requirement resolution
Financial education/resolution
A

Reduce patient duplicates with biometrics

Consequences of incorrect identification -
Wrong medical history
Billing info is not correct
Incorrect medical record

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5
Q

2.4. Medicaid

Federally aided, state operated and administered.
Some states expanded Medicaid with PPACA and extended to childless adults (BadgerCare).
Additional funding if expanded to 133% poverty level.

A
Medicaid covers SNF if >21.
Some eligible by spend down and add Value Code 66 to 837.
Claim must include Case #.
Follow HMO rules if Medicaid in HMO.
Medicaid payer of last resort.
Specific documentation for abortions, sterilizations.
Newborn bills must include birth weight.
Also some State-specific requirements.
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6
Q

2.4. TRICARE (formerly CHAMPUS)

For active duty and retired and their families.
National Guard and Reserve and families and survivors.

A

TRICARE Unique Billing Requirements -
Emergency services billed separately from inpatient
Bills submit within 1 year. If TRICARE is secondary, submit claim w/i 90 days of receiving payment from primary payer.
Deduct 10% if no prior auth.

Types of TRICARE Plans

  1. TRICARE PRIME - active duty, HMO, use military treatment facilities, POS option.
    Overseas options
    - US Family Health Plan - use networks of community NFP in six US areas.
    - TRICARE Young Adult - for adult children who have aged out of regular TRICARE (age 21-26).
  2. TRICARE STANDARD AND EXTRA - FFS plan with deductible and coinsurance. EXTRA - in network, STANDARD - non-network provider used.
  3. TRICARE for LIFE
    Supplement to Medicare.
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7
Q

2.6. Price Transparency

Need verification of insurance and benefits
Details of coverage and limitations, including site restrictions or # of therapy visits
Network status
Auth or referral requirements
Status of deductible, copay, coinsurance and Max OOP.

Then need to know service involved:
Service or tests
Patient type
Determine how provider is paid -
Identify which other providers may be involved.
Diagnosis
Procedure codes
Any anticipated follow-up care
A

Provide estimate with worksheet or estimator tool.

For Financial Assistance application -
Demographic - # of family members for poverty guidelines, address for Medicaid.
Income - Tax return or copies of 3 most recent pay stubs.
Assets - exclude primary residence
Expenses - classify as medically indigent if medical bills exceed certain % of expenses.

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