Billing

Question 1

Title XVIII of the Social Security Act (SSA) is also known as…..

Answer 1

Medicare

Question 2

The 4 qualifiers for Medicare are….

Answer 2

-elderly (65+)
-permanent disability
-end stage renal disease (ESRD)
-Lou Gehrig’s disease

Question 3

I’m The 4 parts of Medicare are…

Answer 3

Part A
Part B
Part C
Part D

Question 4

MDCR Part A covers_______

MDCR Part B covers_______

MDCR Part C covers_______

MDCR Part D covers_______

Answer 4

A - Inpatient hospital stays
B - Medical (review chart)
C - advantage or replacement
D - Drugs

Question 5

5 types of Medicare Advantage plans

Answer 5

• Health Maintenance Organizations (HMO)
• Preferred Provider Organizations (PPO)
• Private Fee-for-service plans
• Special needs plans
• Medical Savings Accounts (MSAs)

Question 6

MDCR advantage plan in which members must generally get healthcare from providers in the plan’s network is aka ______

Answer 6

HMO

Question 7

MDCR advantage plan in which members can see any doctor or provider that accepts Medicare and don’t need a referral for specialist is aka______

Answer 7

PPO

Question 8

MDCR advantage plan that allows members to go to any provider that accepts the plans terms is aka _______

Answer 8

Fee-for-service

Question 9

MDCR advantage plan, which are limited to people in long-term care facilities (that are eligible for MDCR) and is only available in limited areas is aka _____

Answer 9

Special needs plans

Question 10

MDCR advantage plan with two parts, a high deductible, plan, and an account Medicare deposits, money into is aka _______

Answer 10

Medical Savings Accounts (MSAs)

Question 11

What is a formulary?

Answer 11

A list of medicare cover drugs

Question 12

Private firms that process Medicare claims, enroll providers, provide education on billing requests, and answer provider and patient questions are also aka _____

Answer 12

Medicare administrative contractor (MAC)

Question 13

DME stands for_______

Answer 13

Durable medical equipment

Question 14

What are the advantages of the Medicare participating physician program?

Answer 14

-higher fee schedule payments
-fewer collection efforts
-publicity
-Government approval to display Medicare emblems

Question 15

Are workers compensation regulations determined by the state or federal government?

Answer 15

State

Question 16

Who is eligible for Tricare? What is the exception?

Answer 16

-active duty, spouses, dependents, and retirees (unless they are Medicare eligible)

Question 17

The military member eligible for Medicare is called the ____

Answer 17

Sponsor

Question 18

Under Tricare, when does the sponsor become eligible for benefits? What about other members?

Answer 18

-sponsor - on the first day of active orders
-others - after sponsor has been in active duty for 30 days

Question 19

The Tricare supplement to Medicare is called ________

Answer 19

Tricare for Life

Question 20

What is a NAS and when is is required?

Answer 20

Non-availability Statement. It’s required before non emergent inpatient services at a non-military treatment facility.

Question 21

Title XXI of the Social Security Act is aka ________

Answer 21

CHIP - Children’s Health Insurance Program

Question 22

Who qualifies for CHIP and are the standards set by state or federal governments?

Is the program state or federally funded?

Answer 22

Children, whose families fail to qualify for Medicaid but cannot afford private insurance.

The states design the eligibility standards

It is jointly funded by state and federal governments

Question 23

Individual policies purchased by people who do not get insurance through an employer, are aka ____

Answer 23

Commercial Insurance Policies

Question 24

Medicare is secondary to…..(6)

Answer 24

-employer coverage (either patients or spouses extended coverage)
-work comp
-black link coverage
-auto
-liability
-VA*

Question 25

If a patient’s coverage changes to a Medicare HMO in the middle of an inpatient stay, is Medicare or the HMO responsible?

Answer 25

Medicare

Question 26

TRICARE is the last payer after other health plans except ______

Answer 26

Medicaid

Question 27

When is the VA primary to Medicare and vice versa?

Answer 27

The patient can choose the VA over Medicare, but must bill VA first. If patient chooses Medicare over, VA claim must be submitted to Medicare as primary and not submitted to the VA.

If Medicare is primary, no payment will be made by the VA

Question 28

Does liability and property casualty insurance fall as primary or secondary most of the time?

Answer 28

Primary

Question 29

Define the following HIPPA standard transportations
1. 835
2. 837 I/P
3. 279
4. 271
5. 267
6. 277

Answer 29

1. 835 - healthcare payment remittance
2. 837 I/P - institutional or professional claim file
3. 270 - healthcare eligibility inquiry
4. 271 - healthcare eligibility response.
5. 267 - healthcare claim status inquiry.
6. 277 - healthcare claim status response.

Question 30

When do you use the following?
-ICD 10
-POA
-CPT 4
-HCPCS

Answer 30

-ICD 10 - diagnosis an inpatient procedures
-POA - inpatient claims
-CPT 4 - outpatient procedures
-HCPCS - outpatient procedures

Question 31

What does AAHAM stand for?

Answer 31

American Association Healthcare Administrative Managment

Question 32

The two federal agencies governing healthcare change are CMS and OIG. What to those acronyms stand for?

Answer 32

CMS - Center for MDCR/MDCD Services
OIG - Office of Inspector General