To receive Medicare benefits, individuals must be eligible under one of six beneficiary categories: list them
1. Aged sixty-five or older
2. Disabled adults
3. Disabled individuals before age 18
4. Spouses
5. Retired federal employees enrolled in the Civil Service Retirement System, CSRS, and their spouses, over age sixty-five;
6. Individuals with End Stage Renal
When should a Patient eligibility for Medicaid should be checked?
a Patient eligibility for Medicaid should be checked each time they make an appointment and before they see the physician.
EMEVS specifies
eligibility dates, the type of plan, and if a copayment or coinsurance is required and a second form of ID
When should a Patient eligibility for Medicaid be checked
each time they make an appointment and before they see the physician.
On claims, CMS will not accept signatures that use
facsimiles of original written/electronic signatures.
The content of claims and taxonomy codes are set by
NUCC, National Uniform Claim Committee.
Medical Assistant
...
New patient-
patient who has not seen a provider within the past 3 years
Established patient-
patient who has seen a provider within the past 3 years
%$#&
...
The encounter form is
a source of billing information for the medical insurance specialist.
A patient information form gathers
the patient's personal information, employment data and insurance information
Can the subscriber of the insurance may be the same person as the patient. true or false
True
The subscriber of the insurance may be
the same person as the patient.
New patients have not received professional services from a provider within
three years.
Established patients have received professional services from a provider within
three years.
New patients have received professional services from a provider within three years. Is this true or false
False
Established patients have not received professional services from a provider within three years. true or false
False
Charges usually collected at the time of service are
copayments, noncovered or overlimit fees, charges of nonparticipating providers, and charges for self-pay patients.
How many charges are usually collected at the time of service
Four
If a husband has employer insurance, but is also eligible for benefits as a dependent under his spouse's insurance plan, his spouse's policy
is secondary.
Give an example of a primary and a seconday policy for a husband
If a husband has employer insurance, but is also eligible for benefits as a dependent under his spouse's insurance plan, his spouse's policy is secondary.
A certification number for a procedure is the result of
referral and authorization.
Is the certification number for a procedure is the result of referral and authorization.
yes
On HIPAA claims, a required data element must be
supplied
On HIPAA claims, what must be supplied
a required data element must be supplied.
On a claim form, the NPI is used to report the
provider identifier
The number of the HIPAA Professional claim transaction is
X12 837P.
The modifier that indicates a signed ABN is on file is
GA
Carrier block is a data entry area located in the
upper right of the CMS-1500 claim form that allows for a four-line address for the payer.
Taxonomy codes are administrative codes under HIPAA used to report a
physician's specialty when it affects payment.
What are Taxonomy codes
Taxonomy codes are administrative codes under HIPAA used to report a physician's specialty when it affects payment.
Claim scrubber is software that checks claims to permit error correction for submission of clean claims. true or flase?
true
Is Clean claims, claims that include all required data elements?
yes
It is important to determine primary insurance for patients who have more than one health insurance plan to ensure submission of a claim with accurate payer information. This is necessary to reduce any delays in processing claims for submission to the wro
...
The three major methods of transmitting claims electronically are:
1. Direct transmission to the payer
2. Clearinghouse use
3. Direct data entry, DDE
Medicare consisted of
Parts A and B, which covered hospital care and provider's services. Later, two additional parts were added: Part C, Medicare Advantage, allows Medicare beneficiaries to enroll in a managed care plan to reduce their out of pocket expenses; Part D, is the p
What does the Original Medicare plan requires?
a premium, a deductible and coinsurance.
Original Medicare only is
Parts A and B, which covered hospital care and provider's services.
What are supplemental insurance plans purchased by Medicare beneficiaries to reduce their out of pocket costs. These would be used as secondary plans, not in place of Medicare.
Medigap plans
Under Medicare's global surgical package regulations, a physician may bill a
a patient separately for diagnostic tests required to determine the need for surgery
A physician may bill a patient separately for diagnostic tests required to determine the need for surgery under what regulations?
Under Medicare's global surgical package regulations
Limiting charge is
the highest fee nonparticipating providers in Medicare may charge for a particular service.
Does An individual who has been receiving Social Security disability benefits for four years eligible for Medicare coverage without paying a premium
NO
What is MSN?
Medicare Summary Notice, is the type of remittance advice from Medicare to beneficiaries to explain how benefits were determined.
PQRS, Physician Quality Reporting System, was established by CMS to do what
collect and report patient-care performance measures that are established annually.
What Medi-Medi beneficiaries are eligible for
both Medicare and Medicaid.
What is referred to as the payer of last resort
Medicaid
Spenddown requires
beneficiaries to pay part of their monthly medical expenses, until they qualify for Medicaid based on income/assets
Applicants who have high medical bills and whose incomes exceed state limits
may be eligible for ....
healthcare coverage under a state medically needy program
Who must use a specific provider?
People classified as having restricted status must see a specific provider for treatment
Does The Medicaid Alliance for Program Safeguards oversees states' fraud and abuse efforts.
Yes
What does The Medicaid Alliance for Program Safeguards oversees?
States' fraud and abuse efforts.
The national committee to coordinate Medicaid data elements on healthcare claims is
NMEH, National Medicaid EDI HIPAA Workgroup
To provide services to Medicaid recipients, physicians must sign a contract with...
the HHS, Health and Human Services (or, Department of Health and Human Services).
Patient eligibility for Medicaid should be checked
each time they make an appointment and before they see the physician.
EMEVS
Electronic Medicaid Eligibility Verification System
Is it is important to determine primary insurance for patients who have more than one health insurance plan to ensure submission of a claim with accurate payer information?
Yes
Why is it necessary that Health insurance specialists must examine patient information forms and health insurance cards to determine if more than one health insurance policy is in effect.
It is then necessary to determine which is the primary payer based on coordination of benefits rules.
What is CSRS
the Civil Service Retirement System
What Program Safeguards oversees states' fraud and abuse efforts.
The Medicaid Alliance Program
What are theses three things?
1. Direct transmission to the payer - under this method, providers and payers exchange transactions directly without using a clearinghouse. This requires special technology and the provider must supply all HIPAA data elements
The three major methods of transmitting claims electronically
The three major methods of transmitting claims electronically are:
1. Direct transmission to the payer - under this method, providers and payers exchange transactions directly without using a clearinghouse. This requires special technology and the provider must supply all HIPAA data elements and follow specific EDI forma