Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Amy Bill-cp 11, 14
billing for chapter 11 and 14
| Question | Answer |
|---|---|
| basis for federal government Medicaid allocations to states | FMAP-federal medicaid assistance percentage |
| people who receive assistance from government | categorically needy |
| program that provides cash assistance for low-income families | TANF-temporary assistance for needy families |
| Medicaid eligibility 1 of 2: | people recieving TANF, people eligible for TANF but receiving assistance, foster care/adoption assistance under Social Security Act,Children under 6 from low income families, people who lose cash assistance when income or SS exceed allowable limits |
| Medicaid eligibility 2 of 2 | infants born to MD eligible preg. women, 65+ or legally blind or disabled people who get SSI, certain low income MR recipients (medi/medi) |
| payor of last resort | Medicaid |
| who runs the medicaid programs? | the state |
| offers health insurance coverage for uninsured children | SCHIP-state children's health insurance program |
| Medicaid's prevention, early detection, and treatment program for eligible children under 21 | EPSDT-early and periodic screening, diagnosis, and treatment |
| law that established TANF and tightened MD eligibility requirements | welfare reform act |
| state guidelines for eligibility for MD | income, current assets, assets recently transferred into another persons name |
| classification for people with high medical expenses and low financial resources | medically needy |
| state based MD program requiring beneficiaries to pay part of their MONTHLY medical expenses | spend down |
| T/F-eligibiity should be checked each time pt makes appointment and before they see physician | true |
| how many pieces of ID should a pt present? | 2 |
| category of MD beneficiary that rules them out of benefits for a period of a time | restricted status-can be monthly |
| MD covered services | inpatient/outpt hospital svs, physican svc, ER svc, lab/xrays, prenatal care, EPSDT under 21 (physical, immunizations and child vaccs, age related counseling), HHC, family planning, nurse/midwfe, pediatric, rural health clinics, fed qualified health cntr. |
| miscellaneous svcs that MD can choose to cover per state | chiropractic, clinic svc, vison, prescription, prosthetic, transportation, rehab/physical therapy, home/community based care (chronic imparment care) |
| fee for service MD plans | straight MD |
| MD Plans which include a network, PCP, referrals and have no copay | managed care MD plans |
| T/F-providers who take MD patients must sing a contract with the dept of health and human services (HHS) | True |
| T/F-it is important to determine whether the pt has other insurance coverage | true-and bill MD last! |
| person eligible for both MR and MD | Medi-Medi beneficiary, medicare sends bill to MD right after adjudication for payment instead of the office having to submit to MD themselves (cross over claim) |
| claim for a MR or MD beneficiary | cross over claim |
| follow the general instruction for correct claims, enter particular MD data elements | Medical insurance specialists |
| things insurance specialist need to know when filing claims | where to file claims,proper MD coding methods, unacceptable billing practices, actions to take after filing claim. |
| unnacceptable billing practices (MD) | billing for scs: not medically necessary, not provided, or billing twice, submitting individual procedures that are part of global procedure (unbundling),billing for indiv provider who is part of a group. |
| some groups covered by state and NOT federal guidelines; | ages, blind or disabled with incomes below ded pov level, people institutionalized yet receiving care at home/comuity care, children under 21 and meet TANF, recipients of state supplemt. income |
| payors 5 steps to adjudicate claims | initial processing, automated review, manual review, determination, payment |
| payers first perform initial processing checks on claims, rejecting those with missing or clearly incorrect info | initial processing |
| claims processed through the payer's automated medical edits | automated review |
| manual review is done if required | manual review |
| payer makes determination of whether to pay, deny, or reduce the claim | determination |
| payment is sent with remittance advice/explanation of benefits (RA/EOB) | payment |
| situation in which a pt receieves independent care from 2 or more physicians on the same date | concurrent care |
| claim status when the payer is developing the claim | suspended |
| process of gathering information to adjudicate a claim | development |
| payer's decision about the benefits due for a claim | determination |
| refusal by a plan to pay for a procedure that doesnt meet itsmedical necessity criteria | medical necessity denial |
| document describing a payment resulting from a claim adjudication | remittance advice-RA |
| document showing how te amount of a benefit was determined | EOB-explanation of benefits |
| report grouping unpaid claims transmitted to payers by the length of time they remain due | insurance aging report |
| states' law obligating carriers to pay clean claims within a certain time period | propt-pay laws |
| classification of accounts revievable by length of time | aging |
| time period in which a health plan must process a claim | claim turnaround time |
| claim status wen the payer is waitingfor information | pending |
| electronic and paper RA/EOBs contain (data they contain) | heading with payer/provider info, pymt info on each claim with adjustment codes, ttal amt pd for all claims, glossary defining adjustment codes that appear on document. |
| explain payer's payment decision | RARC-remittance advice remark codes |
| unique claim control number reported on the RA/EOB is first used to match up claims sent/pymt receieved, and then....(know all 5) | basic data ckd against claim, billed procedures verified, pymt for each CPT ckd against expected amt, ajudstment codes reviewed, items identified for follow up. |
| process for posting payments/managing denials (know all 4) | pymt deposited into practices bank and posted in practice mgmt program and applied to pt acct, rejected claims corrected and resent, missed procedures billed again, partial pay/denied/downcoded claims analyzed then appealed/billed to pt or written off. |
| electronic routing of funs between banks | EFT-electronic funds transfer |
| software feature enabling automatic entry of payments on a remittance advice | autposting |
| process of verifying tha tthe totals on the RA/EOB check out mathematically | reconcilliation |
| request for reconsideration of a claim adjudication | appeal |
| person/entity exercising the right to receive benefitys (pts and providers) | claimant |
| one who appels a claim decision (pts and providers)-each payers has a graduated level of appeals, deadlines, and med review programs to help them | appellant-also called arbitration |
| MR par providers 5 stepts in appeal rights | redetermination (first level of MR appeal process), MRN-medicare redetermination notice for resoli f1st apal or FFS claims, reconsideration, administrative law judge, MR appeals court, Federal court (juditial review) |
| T/F-filing an appeal may result in payment of a denid/reduced claim | true |
| improper or excessive payments resulting from billing errors | overpayments (yes you have to give the money back!) |
| formal complaint against a payer filed with state insurance commission by a practice (must be factual) | grievance |
| when an insurance company automatically sends necessary data to secondary payer | COB-coordination of benefits (kind of like cross overs) |
| federal law requiring private ayers to be the primary payers for MR beneficiaries claims | MSP-medicare secondary payer |
| identifies situations in which MR is the secondary payer-exp bcbs billd before MR | medical insurance specialist |
| when MR is the secondary payer | pt covered by employer GHP/spouses plan, pt is disabled/under 65 and covered by employee GHP, svcs covered by WC, svcs are for auto accident injuries, pt is vet who chooses to receieve svcs through dept of veteran affairs |
Created by:
100000244695396