15443249
Description
Flashcards by Rynzelle Spraggs, updated more than 1 year ago
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Created by Rynzelle Spraggs
over 5 years ago
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| Question | Answer |
| MEDICAID | Medicaid is a health insurance program for low-income individuals and families that cannot afford healthcare costs. |
| MEDICAID ELIGIBILITY | 1. 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 |
| MEDICAID BENEFITS | State 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). |
| Early and Periodic Screening, Diagnostic and Treatment (EPSDT) | The EPSDT benefit provides comprehensive and preventive healthcare services for enrolled children under the age of 21. |
| Prior Authorization | The 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. |
| Medicaid Claims Filing Requirements | Medicaid 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. |
| Medicaid Claims Completion Guidelines | Claims 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). |
| Common Denials for Medicaid Claims | 1. Recipient not eligible 2. Recipient covered by another payer 3. Frequency of service exceeded 5. Diagnosis invalid for date of service |
| Medigap | Medigap 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 |
| Medigap Claims Processing | Information 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 |
| Cross-over | The transfer of claims information to Medigap insurance |
| Medigap Transfer | A claim in which a beneficiary assigns their benefits under a Medigap policy to a participating physician, provider, or supplier |
| EOMB | Explanation 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. |
| COBRA | Coordinaton of Benefits Agreement |
| TRICARE (FORMERLY CHAMPUS) | the Department of Defense healthcare program for military families and retirees. |
| CHAMPVA (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 |
| DEPARTMENT OF DEFENSE DEFINITION OF CASE MANAGEMENT | CASE 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. |
| TRICARE Prime | MTFs 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. |
| TRICARE Extra | Preferred 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 |
| TRICARE Standard | A 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 |
| CHAMPVA | fee-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. |
| Beneficiary Counseling and Assistance Coordinators (BCACs) | Available to answer questions to help the member solve healthcare related problems, |
| CAC | TRICARE Common Access Cards |
| DBN | DoD ID Benefits number -- 11 digits when verifying the cardbearer's TRICARE eligibiity and filing claims |
| DoD ID | 10-dg9t number on the ID card and it is not used for eligibility or filing claims |
| COMMON DENIALS FOR TRICARE | 1. Not eligible on DEERS 2. No authorization 3. Not medically necessary |
| TRICARE Appeals | TRICARE 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. |
| Common Reasons for a TRICARE claim review | Allowed 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 |
| Which charges are denied through TRICARE | Only charges denied as services not covered by TRICARE or not medically necessary can be appealed through TRICARE. |
| What should be included on the TRICARE appeal | the 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 |
| RBRVS/RVU Concepts | It 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 |
| RVU | Relative 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 |
| GAF (GPCI) | Geographic Adjustment Factor (Geographic Practice Code Index) applied for local code differences for the components (work, practice expense, and PLI) nationally |
| Status Codes | reflects Medicare coverage and payment policy. It can indicate if a service is payable, noncovered, bundled into another service, etc. |
| Status Code A | Active Code (Payable under the physician fee schedule) PFS |
| Status Code B | Bundled code (Payment for covered services that are always bundled into payment for other services) |
| Status Code C | Carrier -priced code (CMS contractor establishes RVUs and payment amounts for these services) |
| Status Code E | Excluded by regulation (No payment made under PFS) |
| Status Code I | Not valid for Medicare purposes (Medicare uses another code for reporting of any payment of these services) |
| Status Code M | Measurement codes (Indicates PQRS code. No payment and no RVUs attached with these codes). |
| Status Code N | Non-Covered service (No Medicare payment is made for these services. RVUs may be shown, but they are not used by Medicare. |
| Status Code P | Bundled/Excluded codes (No separate payment is made and no RVUs attached with these codes. |
| Status Code Q | Therapy functional information code (Used for reporting purposes. No separate payment is made for these services) |
| Status Code R | Restricted coverage (Special coverage instructions apply. If no RVUs are shown, the service is carrier-priced) |
| Status Code T | Paid 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) |
| Status Code X | Statutory 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) |
| PC/TC Indicator | Indicates a service's technical and professional component breakdown. |
| PC/TC Indicator 0 | Physician Service Codes |
| PC/TC Indicator 1 | Diagnostic tests and radiology services |
| PC/TC Indicator 2 | Professional component onl codes |
| PC/TC Indicator 3 | Technical Component only codes |
| PC/TC Indicator 4 | Global test only codes |
| PC/TC Indicator 5 | Incident-to codes |
| PC/TC Indicator 6 | Laboratory physician interpretation codes |
| PC/TC Indicator 7 | Private practice therapist's service |
| PC/TC Indicator 8 | Physician interpretation codes |
| PC/TC Indicator 9 | Not applicable |
| Global Surgery Indicators | this field shows hoa many global days, if any, are applicable to the code. |
| Global Surgery Indicators 000 | 000 = Global surgery period includes day of procedure only (Endoscopic or minor procedures on same day are included) |
| Global Surgery Indicators 010 | 010 = 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) |
| Global Surgery Indicators 090 | 090 = 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 |
| Global Surgery Indicators MMM | Global surgery period does not apply; used for maternity codes |
| Global Surgery Indicators XXX | Global surgery period does not apply |
| Global Surgery Indicators YYY | Global surgery period determined by carrier |
| Global Surgery Indicators ZZZ | Code falls within global surgery period for another service (Service always included in the global period of the other service) |
| Three fields following the global surgery days field breakdown | pre-operative post-operative intra-operative |
| Multiple procedure | indicates the applicable payment adjustment rule for multiple procedures |
| Multiple procedure 0 | no payment adjustment rules for multiple procedures apply |
| Multiple procedure 1 | Standard 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) |
| Multiple procedure 2 | Standard payment adjustment rules for multiple procedures apply (100 percent for the first, 50 percent for all additional procedures) |
| DEERS | Defense Enrollment Eligibility Reporting System (Database) |
| DoD Benefits Number (DBN) | 11 digit number for verifying the cardbearer's TRICARE eligibility and filing claims. |
| DoD ID number | I0 digit number on the ID card and is not used for eligibility or filing clais |
| Two types of TRICARE providers | network providers and non network providers |
| Multiple procedure 3 | special 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) |
| Multiple Procedure 4 | Special 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. |
| Multiple Procedure 5 | Subject to 20 percent of the practice expense component for certain therapy services (25 percent reduction if an institutional setting) |
| Multiple Procedure | If 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. |
| The Clinical Prior Authorization Program | 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. |
| Multiple Procedure 6 | Special 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 |
| Multiple Procedure 7 | Special 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. |
| Technical Component 9 | Concept does not apply |
| Bilateral surgery | indicates services subject to payment adjustment for bilateral procedures. |
| Bilateral surgery 0 | 150 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. |
| Medigap | Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover. |
| Bilateral surgery 1 | 150 percent payment adjustment for bilateral procedures applies. Payment is based on 150 percent of the fee schedule amount of the single code |
| Bilateral surgery 2 | 150 percent payment adjustment for bilateral procedures does not apply |
| Bilateral surgery 3 | The 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. |
| Bilateral surgery 9 | Concept does not apply |
| Assistant at Surgery | indicates services where an assistant at surgery is never paid for per the Medicare Claims Manual |
| Assistant at Surgery 0 | Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity |
| Assistant at Surgery 1 | Statutory payment restriction for assistants at surgery applies to this procedure. Assistant surgery may not be paid. |
| Assistant at Surgery 2 | Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid. |
| Assistant at Surgery 9 | Concept does not apply. |
| Co-surgeons | indicates services for which two surgeons, each in a different specialty, may be paid. |
| Co-surgeons 0 | Co-surgeons not permitted for this procedure |
| Co-surgeons 1 | Co-surgeons cannot be paid. but supporting documentation is required to establish the medical necessity of two surgeons for this procedure. |
| Co-surgeons 2 | Co-surgeons permitted and no-documentation required if the two-specialty requirement is met |
| Co-surgeons 9 | Concept does not apply |
| Team Surgery | indicates surgeons for which team surgeons may be paid |
| Team surgeons 0 | Team surgeons not permitted for this procedure |
| Team surgeons 1 | Team surgeons could not be paid, but supporting documentation is required to establish medical necessity of a team. |
| Team surgeons 2 | Team surgeons permitted. These are paid by report. |
| Team surgeons 9 | Concept does not apply. |
| Endoscopic base code field | The last field in the global surgery indicators that identifies endoscopic base code for any code with a multiple surgery indicator of 3 |
| Accept Assignment | A provider agrees to accept the amount allowed by the insurance company as payment in full |
| Advance Beneficiary Notice | A 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 |
| Civilian Health and Medical Program of tf the Department of Veteran Affairs CHAMPVA | Healthcare 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 |
| Crossover Claim | The transfer of processed claim data fromMedicare operatons to Medicaid (or state) agencies and Medigap insurers |
| Early and Periodic Screening, Diagnostic and Treatment (EPSDT) | Medicaid benefit that provides comprehensive and preventive healthcare services for enrolled children under the age of 21. |
| Medigap | Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that Original Medicare does not cover. |
| National 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. |
| Non-Participating Provider | A physician, hospital or other healthcare entity that does not have a participating agreement with an insurance plan's network. |
| Participating Provider | A physician, hospital, or other health-care entity that is part of an insurance plan's network. |
| Relative Value Unit | Measure of value used by Medicare in the resource based relative value system |
| Resourced Based Relative Value System | A 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 |
| TRICARE | The Department of Defense healthcare program for military families and retirees. |
| Medicare Eligibility | Most people 65 and older People with certain disabilities People with ESRD |
| Medicare Parts | 4 parts Part A (Hospitals) Part B (Physician Visits) Part C (Managed Care) Part D (Prescription) |
| Medicare -- Contractual Options | Participating Providers Non-Participating Providers |
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