Flashcards
Government Carriers/Medicare, Mediaid, TRICARD
Cards in this deck (120)
- 1MEDICAIDMedicaid is a health insurance program for low-income
individuals and families that cannot afford healthcare costs. - 2MEDICAID ELIGIBILITY1. US Citizen
2. Proof of eligible immigration
3. SSN
4. TANF
5. Children under the age of 6 --family FPL
6. Pregnant women -- FPL
7. SSI
8. Foster Care or adoption assistance
9. Fall under protected group
10. Children born after 1983, are under 19 and in families w/ income at or below FPL - 3MEDICAID BENEFITSState Medicaid
agencies can choose to provide other optional benefits through
the state Medicaid program. Medicaid programs must provide
the mandatory benefits to eligible individuals to receive
matching federal funds known as Federal Medical Assistance
Percentage (FMAP). - 4Early and Periodic Screening, Diagnostic and Treatment (EPSDT)The EPSDT benefit provides comprehensive and preventive
healthcare services for enrolled children under the age of 21. - 5Prior AuthorizationThe Clinical Prior Authorization Program was implemented to manage drug classes that require additional monitoring, ensuring drugs are being
prescribed for the right patients and the appropriate reasons,
and monitor drug expenditures. - 6Medicaid Claims Filing RequirementsMedicaid cannot make payments to recipients, so the provider
that performed the service is required to file a claim and agree
to accept assignment (accept the allowed amount as payment
in full). Some states require providers to submit claims electronically, unless a claim requires attachments, while others
allow providers to choose how they wish to submit. Timely
filing requirements will also vary from state to state. Medicaid is always considered the payer of last resort. - 7Medicaid Claims Completion GuidelinesClaims for Medicaid services are submitted on a CMS-1500 form using the specific code sets adopted by HIPAA. This
includes HCPCS Level II codes, CPT® codes, ICD-10-CM codes, and National Drug Codes (NDC). - 8Common Denials for Medicaid Claims1. Recipient not eligible 2. Recipient covered by another payer 3. Frequency of service exceeded 5. Diagnosis invalid for date of service
- 9MedigapMedigap refers to a Medicare supplemental policy that is sold by
private insurance companies to help cover some of the costs that
original Medicare does not cover, like deductibles, copayments,
and coinsurances. Some policies may offer coverage for services
not covered by Medicare, like coverage if a patient is injured or
becomes ill while traveling outside the United States. Medigap policies usually don’t cover prescription drugs, long-term care, vision care, dental care, hearing aids, eyeglasses, or private duty
nurses. Patients pay a separate premium to the Medigap insurer - 10Medigap Claims ProcessingInformation and instructions on processing of Medigap claims
can be found in the Medicare Claims Processing Manual, chapter 28—Coordination with Medigap, Medicaid, and other complimentary insurers. If the Medicare beneficiary has authorized payment to be made to the physician or provider, Medicare must transfer the Medicare claims information to
the Medigap insurer. This is indicated by the signature on file notice in box 13 on the CMS-1500 form. A claim in which a beneficiary assigns their benefits under a Medigap policy to a participating physician, provider, or supplier is called a
mandated Medigap transfer. The transfer of the claims information to the Medigap insurance is called cross-over - 11Cross-overThe transfer of claims information to Medigap insurance
- 12Medigap TransferA claim in which a beneficiary assigns their benefits under a Medigap policy to a participating physician, provider, or supplier
- 13EOMBExplanation of Medicare Benefits, sent when items in block 9 is completed and accurate and the physician is a participating provider.
MA18 The claim information is also being forwarded to the patient’s supplemental insurer. Send any questions
regarding supplemental benefits to them
MA19 Information was never sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer. - 14COBRACoordinaton of Benefits Agreement
- 15TRICARE (FORMERLY CHAMPUS)the Department of Defense healthcare program for military families
and retirees. - 16CHAMPVA (THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERANS AFFAIRS)healthcare program in which the Department of Veterans Affairs covers
spouses, widows and widowers, and the children of a veteran who is rated permanently and totally disabled due to a service-connected disability, died of a service-connected disability,
or died on active service and the dependents are not eligible
for TRICARE. In specific instances, veterans may themselves
qualify for CHAMPVA, also - 17DEPARTMENT OF DEFENSE DEFINITION OF CASE MANAGEMENTCASE MANAGEMENT AS A COLLABORATIVE PROCESS UNDER THE POPULATION HEALTH CONTINUUM WHICH ASSESSES, PLANS, IMPLEMENTS, COORDINATES, MONITORS, AND EVALUATES OPTIONS AND SERVICES TO MEET AN INDIVIDUAL'S HEALTH THROUGH COMMUNICATION AND AVAILABLE RESOURCES TO PROMOTE QUALIFY COST-EFFECTIVE OUTCOMES.
- 18TRICARE PrimeMTFs are the principal source of healthcare, civilian clinics may be used in some cases.
All active duty service members are eligible for TRICARE Prime.
Managed care option
Enrollees choose a primary care manager (PCM) who coordinates
patient care, maintains patient health records, and refers patients to specialists, when necessary.
No annual deductible
No annual enrollment fee for active duty members and their families. - 19TRICARE ExtraPreferred Provider Option
No enrollment requirement
No annual fee
Deductible and coinsurance for outpatient care.
Not required to have a primary care manager or request a referral to see a specialist
Not available to active duty service members
Co-payments are 5 percent lower than TRICARE standard
Physician or provider is responsible for filing claims - 20TRICARE StandardA fee-for-service option that allows enrollees the most choices
TRICARE is the authorized provider
Providers are not required to participate in the TRICARE network but must be certified as an authorized provider by the manager care support contractor (MCSC) in the region they are in.
No enrollment requirement or annual fee
There is a deductible and coinsurance for outpatient care
Not available to active duty service members
Co-insurance is 20 percent of allowed charges for covered services
Enrollees have to file their own claims - 21CHAMPVAfee-for-service insurance
enrollees may see any provider they choose and do not need a PCM
There is a deductible and coinsurance for care
You cannot be eligible for TRICARE
Pays 75% of the allowable amount for covered outpatient services. - 22Beneficiary Counseling and Assistance Coordinators (BCACs)Available to answer questions to help the member solve healthcare related problems,
- 23CACTRICARE Common Access Cards
- 24DBNDoD ID Benefits number -- 11 digits when verifying the cardbearer's TRICARE eligibiity and filing claims
- 25DoD ID10-dg9t number on the ID card and it is not used for eligibility or filing claims
- 26COMMON DENIALS FOR TRICARE1. Not eligible on DEERS
2. No authorization
3. Not medically necessary - 27TRICARE AppealsTRICARE allows for a review of a claim without opening an appeal. If there is a concern about how a claim is processed, the provider can request a claim review by sending a letter with the reason for requesting the claim review, a copy of the claim, the remittance advice, supporting medical records, and any new information needed for the review.
- 28Common Reasons for a TRICARE claim reviewAllowed amount disputes
l
Charges denied as “Included in a paid service”
l
Charges denied as “Requested information not received”
l
Claim denied as “Provider not authorized”
l
Claim Check denials
l
Coding issues
l
Cost-share and deductible issues
l
Eligibility denials
l
Other health insurance issues
l
Penalties for no authorization
l
Point-of-service disputes (Exception: Point-of-service for
emergency services is appealable.)
l
Third party liability issues
l
Timely filing limit denials
l
Wrong procedure code - 29Which charges are denied through TRICAREOnly charges denied as services not covered by TRICARE or
not medically necessary can be appealed through TRICARE. - 30What should be included on the TRICARE appealthe patient’s name, address, phone number, and sponsor’s
Social Security number
l
printed name of the person submitting the appeal and the
relationship to the patient
l
the reason you are disputing the denial
l
a copy of the EOB or provider remittance
l
additional documents supporting the appeal - 31RBRVS/RVU ConceptsIt incorporates three components of physician services—physician work, practice expense (PE), and professional liability insurance (PLI).
The physician work component comprises about 50.9 percent of the total RVU,
the PE comprises about 44.8 percent of the total RVU,
and the PLI comprises about 4.3 percent of the total RVU - 32RVURelative Value Unit is assigned to each of the work, PE and PLI components
The RBRVS system applies to CPT®
codes, so the work RVU + PE RVU + PLI RVU = Total RVU.
The total RVU is multiplied by a conversion factor (CF) to
obtain the reimbursement for that code.
The CF is the dollar amount by which each CPT® code’s total RVU value is multiplied to obtain the reimbursement for a given service.
The CF is updated annually by CMS. The 2017 CF is $35.8887 - 33GAF (GPCI)Geographic Adjustment Factor (Geographic Practice Code Index)
applied for local code differences for the components (work, practice expense, and PLI) nationally - 34Status Codesreflects Medicare coverage and payment policy. It can indicate if a service is payable, noncovered, bundled into another service, etc.
- 35Status Code AActive Code (Payable under the physician fee schedule) PFS
- 36Status Code BBundled code (Payment for covered services that are always bundled into payment for other services)
- 37Status Code CCarrier -priced code (CMS contractor establishes RVUs and payment amounts for these services)
- 38Status Code EExcluded by regulation (No payment made under PFS)
- 39Status Code INot valid for Medicare purposes (Medicare uses another code for reporting of any payment of these services)
- 40Status Code MMeasurement codes (Indicates PQRS code. No payment and no RVUs attached with these codes).
- 41Status Code NNon-Covered service (No Medicare payment is made for these services. RVUs may be shown, but they are not used by Medicare.
- 42Status Code PBundled/Excluded codes (No separate payment is made and no RVUs attached with these codes.
- 43Status Code QTherapy functional information code (Used for reporting purposes. No separate payment is made for these services)
- 44Status Code RRestricted coverage (Special coverage instructions apply. If no RVUs are shown, the service is carrier-priced)
- 45Status Code TPaid as only service (These services are only paid if there are no other services payable under the PFS billed on the same day by the same provider)
- 46Status Code XStatutory exclusion (These codes represent items or services that are not within the statutory definition of a physician service, so no payment may be made under the PFS)
- 47PC/TC IndicatorIndicates a service's technical and professional component breakdown.
- 48PC/TC Indicator 0Physician Service Codes
- 49PC/TC Indicator 1Diagnostic tests and radiology services
- 50PC/TC Indicator 2Professional component onl codes
- 51PC/TC Indicator 3Technical Component only codes
- 52PC/TC Indicator 4Global test only codes
- 53PC/TC Indicator 5Incident-to codes
- 54PC/TC Indicator 6Laboratory physician interpretation codes
- 55PC/TC Indicator 7Private practice therapist's service
- 56PC/TC Indicator 8Physician interpretation codes
- 57PC/TC Indicator 9Not applicable
- 58Global Surgery Indicatorsthis field shows hoa many global days, if any, are applicable to the code.
- 59Global Surgery Indicators 000000 = Global surgery period includes day of procedure only (Endoscopic or minor procedures on same day are included)
- 60Global Surgery Indicators 010010 =
Global surgery period includes day of and 10 days after surgery
(Minor procedures with pre-op on day of procedure and a 10 day post-operative period all included in the listed RVUs for the code) - 61Global Surgery Indicators 090090 = Global surgery period includes day before, day of, and 90 days after surgical procedure (Major surgery with a 1 day pre-operative period and a 90-day post-operative period included in the listed RVUs for the code
- 62Global Surgery Indicators MMMGlobal surgery period does not apply; used for maternity codes
- 63Global Surgery Indicators XXXGlobal surgery period does not apply
- 64Global Surgery Indicators YYYGlobal surgery period determined by carrier
- 65Global Surgery Indicators ZZZCode falls within global surgery period for another service (Service always included in the global period of the other service)
- 66Three fields following the global surgery days field breakdownpre-operative
post-operative
intra-operative - 67Multiple procedureindicates the applicable payment adjustment rule for multiple procedures
- 68Multiple procedure 0no payment adjustment rules for multiple procedures apply
- 69Multiple procedure 1Standard payment adjustment rules in effect before January 1, 1996 for multiple procedures apply (100 percent for the first procedure, 50 percent for the second, 25 percent for the third and any additional
procedures) - 70Multiple procedure 2Standard payment adjustment rules for multiple procedures apply (100 percent for the first, 50 percent for all additional procedures)
- 71DEERSDefense Enrollment Eligibility Reporting System
(Database) - 72DoD Benefits Number (DBN)11 digit number for verifying the cardbearer's TRICARE eligibility and filing claims.
- 73DoD ID numberI0 digit number on the ID card and is not used for eligibility or filing clais
- 74Two types of TRICARE providersnetwork providers and non network providers
- 75Multiple procedure 3special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (another code with the same base endoscopic procedure code)
- 76Multiple Procedure 4Special rules for the technical component of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family 100 for the first procedure, 50% for each additional procedure.
- 77Multiple Procedure 5Subject to 20 percent of the practice expense component for certain therapy services (25 percent reduction if an institutional setting)
- 78Multiple ProcedureIf a healthcare provider performs multiple procedures during a single patient encounter, Medicare and many commercial insurers will pay the full price for only the highest valued procedure.
- 79The Clinical Prior Authorization Programimplemented to manage drug classes
that require additional monitoring, ensuring drugs are being prescribed for the right patients and the appropriate reasons,
and monitor drug expenditures. - 80Multiple Procedure 6Special rules for the TC of multiple diagnostic cardiovascular services. Full payment for the service with the highest payment under the MPFS. Payment of 75 percent% for subsequent services by the same physician, or physicians of the same group, to the same patient on the same day
- 81Multiple Procedure 7Special rules for the TC of multiple ophthalmology services. Full payment for the service with the highest payment under the MPFS. Payment of 80 percent % for subsequent services by the same physician, or physicians of the
same group, to the same patient on the same day. - 82Technical Component 9Concept does not apply
- 83Bilateral surgeryindicates services subject to payment adjustment for bilateral procedures.
- 84Bilateral surgery 0150 percent payment adjustment for bilateral procedures does not apply
. The bilateral adjustment is
inappropriate for these codes because of physiology or anatomy or because the code description specifically states the procedure is unilateral and there is
an existing code for a bilateral procedure. - 85MedigapMedicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover.
- 86Bilateral surgery 1150 percent payment adjustment for bilateral procedures applies. Payment is based on 150 percent of
the fee schedule amount of the single code - 87Bilateral surgery 2150 percent payment adjustment for bilateral procedures
does not apply - 88Bilateral surgery 3The usual payment adjustment for bilateral procedures does not apply. Payment is based on 100 percent of the fee schedule amount for each side.
This is generally radiology procedures or diagnostic tests which are not subject to the special payment
rules for other bilateral surgeries. - 89Bilateral surgery 9Concept does not apply
- 90Assistant at Surgeryindicates services where an assistant
at surgery is never paid for per the Medicare Claims Manual - 91Assistant at Surgery 0Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity
- 92Assistant at Surgery 1Statutory payment restriction for assistants at surgery applies to this procedure. Assistant surgery may not be paid.
- 93Assistant at Surgery 2Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.
- 94Assistant at Surgery 9Concept does not apply.
- 95Co-surgeonsindicates services for which two surgeons, each in a different specialty, may be paid.
- 96Co-surgeons 0Co-surgeons not permitted for this procedure
- 97Co-surgeons 1Co-surgeons cannot be paid. but supporting documentation is required to establish the medical necessity of two surgeons for this procedure.
- 98Co-surgeons 2Co-surgeons permitted and no-documentation required if the two-specialty requirement is met
- 99Co-surgeons 9Concept does not apply
- 100Team Surgeryindicates surgeons for which team surgeons may be paid
- 101Team surgeons 0Team surgeons not permitted for this procedure
- 102Team surgeons 1Team surgeons could not be paid, but supporting documentation is required to establish medical necessity of a team.
- 103Team surgeons 2Team surgeons permitted. These are paid by report.
- 104Team surgeons 9Concept does not apply.
- 105Endoscopic base code fieldThe last field in the global surgery indicators that identifies endoscopic base code for any code with a multiple surgery indicator of 3
- 106Accept AssignmentA provider agrees to accept the amount allowed by the insurance company as payment in full
- 107Advance Beneficiary NoticeA notice Medicare requires forhealthcare providers to issue to Medicare patients as a definite way to make them aware of the fact that Medicare may not pay for certain services or tests prior to having the services or tests performed in an outpatient setting
- 108Civilian Health and Medical Program of tf the Department of Veteran Affairs CHAMPVAHealthcare program in which the Departmentof Veterans Affairs covers spouses, widows(ers), and the children of a veteran who is rated permanently and totally disabled due to a service connected disability, died of a service connected disability, or died on active service and the dependents are not eligible for TRICARE
- 109Crossover ClaimThe transfer of processed claim data fromMedicare operatons to Medicaid (or state) agencies and Medigap insurers
- 110Early and Periodic Screening, Diagnostic and Treatment (EPSDT)Medicaid benefit that provides comprehensive and preventive healthcare services for enrolled children under the age of 21.
- 111MedigapMedicare supplemental policy that is sold by private insurance companies to help cover some of the costs that Original Medicare does not cover.
- 112National Provider Identifier (NPI)A unique 10-digit identification number required by HIPAA for all healthcare providers in the United States. Providers must use their NPI to identify themselves in all HIPAA transactions.
- 113Non-Participating ProviderA physician, hospital or other healthcare entity that does not have a participating agreement with an insurance plan's network.
- 114Participating ProviderA physician, hospital, or other health-care entity that is part of an insurance plan's network.
- 115Relative Value UnitMeasure of value used by Medicare in the resource based relative value system
- 116Resourced Based Relative Value SystemA systemof payments to physicians for treating Medicare patients that takes into account th work done by the physicians, malpractice insurance, and practice expenses including staff salaries overhead, supplies, and equipment
- 117TRICAREThe Department of Defense healthcare program for military families and retirees.
- 118Medicare EligibilityMost people 65 and older
People with certain disabilities
People with ESRD - 119Medicare Parts4 parts
Part A (Hospitals)
Part B (Physician Visits)
Part C (Managed Care)
Part D (Prescription) - 120Medicare -- Contractual OptionsParticipating Providers
Non-Participating Providers
Information
- Description
- Medicaid is a health insurance program for low-income individuals and families that cannot afford healthcare costs.
- Created by
- Rynzelle Spraggs · Oct 2018
- Updated
- Oct 31, 2018
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