Medicaid and Other State Programs
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ASSIGNMENT 13-1 REVIEW QUESTIONS
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Part I Fill-in-the-Blanks
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1.
Medicaid is administered by state governments with partial federal funding.
2.
Medicaid is not an insurance program. It is a/an assistance program.
3.
In all other states the program is known as Medicaid, but in California the program is called Medi-Cal.
4.
Because the federal government sets minimum requirements, states are free to enhance the Medicaid program. Name two ways in which Medicaid programs vary from state to state.
a.
coverage
b.
benefits
5.
SCHIP means State Children's Health Insurance Program and MCHP means Maternal and Child Health Program and covers children of what age group? Younger than 21 years.
6.
Name the three aid programs for low-income Medicare patients.
a.
Medicaid Qualified Medicare Beneficiary Program
b.
Specified Low-Income Medicare Beneficiary Program
c.
Qualifying Individuals Program
7.
Name two broad classifications of people eligible for Medicaid assistance.
a.
categorically needy
b.
medically needy
8.
The name of the program for the prevention, early detection, and treatment of conditions of children receiving welfare is known as Early and Periodic Screening, Diagnosis, and Treatment. It is abbreviated as EPSDT.
9.
Your Medicaid patient seen today needs long-term hemodialysis services. You telephone for authorization to get verbal approval. Four important items to obtain are:
a.
date of authorization
b.
name of the person who provided authorization
c.
approximate time of day authorization was given
d.
verbal number given by field office
10.
The time limit for submitting a Medicaid claim varies from 2 months to 1 year from the date the service is rendered. In your state, the time limit is (answer will vary, depending on state laws).
11.
The insurance claim form for submitting Medicaid claims in all states is CMS-1500 (08-05) Health Insurance Claim Form.
12.
Your Medicaid patient also has TRICARE. What billing procedure do you follow? Be exact in your steps for a dependent of an active military person.
a.
Bill TRICARE first.
b.
Bill Medicaid second and attach a Remittance Advice, Explanation of Benefits, or check voucher from TRICARE to the billing form.
13.
Five categories of adjudicated claims that may appear on a Medicaid remittance advice document are:
a.
adjustments
b.
approvals
c.
denials
d.
suspends
e.
audit/refund transactions
14.
Name three levels of Medicaid appeals.
a.
regional fiscal intermediary or Medicaid bureau
b.
Department of Social Welfare or Human Services
c.
appellate court
Part II Multiple Choice Questions
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15.
When professional services are rendered, the Medicaid identification card or electronic verification must show eligibility for
a.
day of service.
b.
year of service.
c.
month of service.
d.
week of service.
16.
When a Medicaid patient is injured in an automobile accident and the car has liability insurance, this involves a third-party payer so the insurance claim is sent to
a.
the patient.
b.
the automobile insurance carrier.
c.
the Medicaid fiscal agent.
d.
none of the above.
17.
The only state without a Medicaid program that is similar to those existing in other states that has an alternative prepaid medical assistance program is
a.
Arizona.
b.
California.
c.
Colorado.
d.
New Mexico.
18.
A patient's Medicaid eligibility may be verified by
a.
touch-tone telephone.
b.
modem.
c.
special Medicaid terminal equipment.
d.
all of the above.
19.
When a Medicaid patient requires a piece of durable medical equipment, the physician must
a.
write a prescription.
b.
obtain prior authorization, preferably written.
c.
instruct the patient on how to use the equipment.
d.
give name and address of where to purchase the equipment.
20.
Medicare beneficiaries that are disabled but have annual incomes below the federal poverty level may be eligible for
a.
Medicaid Qualified Medicare Beneficiary Program.
b.
Qualifying Individuals Program.
c.
Specified Low-Income Medicare Beneficiary Program.
d.
all of the above.
Part III True False Questions
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21.
T Cerebral palsy is a condition that qualifies a child for benefits under the Maternal and Child Health Program.
22.
F There is only one type of copayment requirement in the Medicaid program.
23.
T When filing a claim for a Medicaid managed care patient, transmit the claim to the managed care organization and not the Medicaid fiscal agent.
24.
T Providers must enroll for participation in the Medicaid program with the fiscal agent for their region.
25.
T A state agency that investigates complaints of mistreatment in long-term care facilities is the Medicaid Fraud Control Unit (MFCU).
ASSIGNMENT 13-2 CRITICAL THINKING
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1.
Mrs. Ho suddenly experiences a pain in her right lower abdominal area and rushes to a local hospital for emergency care. Laboratory work verifies that she has a ruptured appendix, and immediate surgery is recommended. Is prior authorization required in a
1.
No. Reason: Because it is an emergency and prior authorization is not needed.
In referring to the instructions for completing a CMS-1500 (08-05) claim form for a Medicaid case, which two blocks on the CMS-1500 (08-05) claim form need to be completed for emergency services?
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2.
Block 24CE: What data should be inserted?
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Enter an emergency certification statement.
3.
Block 19 What data should be inserted and/or document attached?
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Include an attachment to the claim with this data.
ASSIGNMENT 13-3 COMPLETE A CLAIM FORM FOR A MEDICAID CASE
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Rose Clarkson:
Generally, Blocks 8 and 11D may be left blank in Medicaid cases unless the regional fiscal intermediary requires that these blocks be completed. For the Medi-Cal program in California, Blocks 24C and 24E are not a requirement for completion.
Diagnostic codes:
428.0 Congestive heart failure
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424.0 mitral valve prolapse
ASSIGNMENT 13-4 COMPLETE A CLAIM FORM FOR A MEDICAID CASE
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Stephen M. Drake:
Block 14: In some regions, the Medicaid fiscal intermediary may request that this block be completed. If so, enter 040420XX. The strep screen test (87081) is found under "Culture, Bacteria, Screening." Other tests listed under Streptococcus are divided in
Diagnostic codes:
463 Acute tonsillitis
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474.02 (chronic tonsillitis and adenoiditis) is included because some Medicaid state guidelines require a chronic diagnostic code indicating that the patient has had this condition and warrants the surgery.
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Diagnostic code 034.0 may be listed in the third position.
Additional Coding
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1.
Using your diagnostic code book, code the symptoms that the patient presented with on May 1, 20xx.
Sypmtom & Code
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a.
Sore throat 462
b.
Enlarged tonsils 474.11
c.
Fever 780.6
ASSIGNMENT 13-5 COMPLETE A CLAIM FORM FOR A MEDICAID CASE
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Barry L. Brooke:
Casting materials and radiographs would be billed by the hospital and would not appear on the physician's insurance billing statement. Block 14: In some regions the Medicaid fiscal intermediary may request that this block be completed. Block 19: This bloc
Diagnostic codes:
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719.06
Effusion of joint, lower leg
844.9
Strain of knee and leg, unspecified site.
Additional Coding
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1.
Refer to Barry Brooke's medical record, abstract information, and code procedures that would be billed by outside providers.
Site
Description of Service Code
a.
College Hospital Radiology Radiographic examination; knee (three views) 73562
b.
College Hospital Central Supply Cast supply; long leg cylinder, adult (11 years +) Q4030
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fiberglass
c.
College Hospital Radiology Magnetic resonance imaging; any joint lower 73721
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extremity, without contrast