Medicare/ Medi-cal Flashcards
(27 cards)
Partnership
Managed care
Administered by blue cross
CSMP
Country medical services program
Began in 2005
Share of cost
SOC
Portion patient must pay before medi-cal will pay
Part A
Hospitals and facilities
Part B
Physicians and outpatient services
Part C
Managed care
Part D
Prescription drugs
Eligibility for Medicare
65+, paid ten years medicare taxes, or qualified disabled and those with end stage renal disease(ESRD)
Medi-medi
Medicare and medi-cal
Medigap
Insurance bought by patient to cover the balance after Medicare pays. Automatically crosses over from Medicare. Patient pays the premium.
When is Medicare second payer
Medicare always pays first except
1) condition related to auto accident or liability insurance
2) patient is working and covered by plan or spouse is covered
3) work related condition.
ABN
Advanced beneficiary notice
Not covered by medical, Not medically necessary
Who is MAC of ca
Palmetto
Medicare part B deductible
20%
TAR
Treatment authorization request
Where patient goes to apply for benefits
County social services
Payer of last resort
Medi-cal
RA
Remittance advice
EOMB
Explanation of medical benefits
MAC
Medicare administrator contractor
Medi-cal is always the last payer when
There is more than one insurance involved
Crossover claim
Also called a claims transfer
Medicare carriers file a medicap claim electronically for participating providers eliminating the need for the provider file an additional claim
Medicare remittance advice
RA
Also called an EOMB
Sent to providers office
Describes payment or denial of a processed claim
MSN
Medical summary notice
Similar to RA or EOMB but sent to beneficiary
