Section 2 - Pre-Service Flashcards
2.2. Order Requirements
Authenticate verbal order by physician written signature.
Qualified person must take verbal order
Waived for immunizations, screening mammography.
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
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.
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.
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
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
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
Reduce patient duplicates with biometrics
Consequences of incorrect identification -
Wrong medical history
Billing info is not correct
Incorrect medical record
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.
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.
2.4. TRICARE (formerly CHAMPUS)
For active duty and retired and their families.
National Guard and Reserve and families and survivors.
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
- 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). - TRICARE STANDARD AND EXTRA - FFS plan with deductible and coinsurance. EXTRA - in network, STANDARD - non-network provider used.
- TRICARE for LIFE
Supplement to Medicare.
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
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.