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MAA 102

Final Review

In coordination of insurance benefits for a child. The parent whose birthdate is first in the calendar year will be the primary plan. The Birthday Rule
Primary Insurance Is billed first
EOB Explanation of Benefits. A document that is received from in the insurance company telling how the claim was paid.
Waiver Acknowledges fiscal responsibility if the insurance company doesn't pay.
Insurance Log A log to track the status of insurance claims
Statue of Limitations For minors- Extended until the child reaches legal age (21 yo) in all states
Managed Care The goal of managed care is to keep costs low. The potential benefit to the enrollee is that premiums are generally lower.
COBRA Provides continuation of healthcare coverage between jobs. (Super expensive)
NPI National Provider Identifier - Issued by CMS (Center for Medicaid & Medicare Services)
OCR Optical Character Recognition (Used to read the CMS-1500. OCR Scannable Red Ink - All Capital Letters - No punctuations)
ADA Americans with Disabilities Act. Concerned with those who discriminate people with disabilities.
Pre-authorization Procedure required by most healthcare plans before a provider carries out a specific procedure or service
Capitation Physician is paid based on the number of patients cared for - Paid per capita - Not on the number of visits or type of service received.
Allowable Charge Maximum a 3rd party payer (Insurance Co.) will pay
Coding Standardization system used to facilitate 3rd party payers
Premiums Payments made to insurance company in return for healthcare benefits
Co-Pay Should be collected at time of service. Usually a fixed amount.
Primary Care Physician Oversees the total healthcare needs of patients. Controls access to specialty care. Also called the Gatekeeper.
Medical Necessity Criteria for payment. Service must meet the standards of good medical practice.
Guarantor Person responsibile for paying the bill.
Co-Insurance Provision by which the policy holder & insurance company share the cost.
Deductible Out of pocket expense paid before coverage goes in to effect.
Exclusion Provision written into insurance contract denying coverage or limiting the scope of coverage.
Tertiary Care Referral of a patient by one specialist to another specialist.
Coordination Of Benefits Agreement on how to process charges when more than one insurance company is involved.
Self Insured/Self Funded Invests their own money in order to pay for it's employee's healthcare needs. 3rd party administrator is used to process claims.
ICD-9-CM International Classification of Disease, 9th Revision, Clinical Modification
ICD-9 is updated when? Every October, for use in January.
What is in Volume 1 of the ICD-9? The Tabular List (Numerical Index) (Used in Outpatient Care)
What is in Volume 2 of the ICD-9? The Alphabetic List (Used in Outpatient Care)
What is in Volume 3 of the ICD-9? Inpatient hospital charges.
What are V-Codes? Used for coding conditions other than illness. The patient is not sick.
What are E-Codes? Identify how accidents happen. Can also determine the place of occurance. Poisoning.
CPT-4 Current Procedural Terminology - 4th Edition
Modifiers Used in the CPT-4. If there are multiple modifiers the code -99 will be used. It means there will be more than one modifier.
Who is eligible for Medicare? +65yo, ESRD, Disabled for 2 years, Kidney Transplant
Claim Form CMS-1500
Medicare Part A Inpatient Hospital care
Medicare Part B Outpatient Care, Phsysician's fees, Diagnostic screening
Medicare Part C Choice of advantage/managed care plans
Medicare Part D Prescriptions
What is the Donut Hole? For Medicare Part D: Phase of coverage where all costs are paid for by the beneficiary, not by Medicare.
What is the Medicare Benefit Period? During of time which a Medicare patient is eligible for hospitalization benefits (Part A). Starts on the first day of admission, Ends after no hospitalization for 60 days. Maximum benefit period is 150 days.
UCR Usual Customary Reasonable
Formulary Listing of drugs the insurance company will pay for. Physician can request a drug to be added if there is good medical reason.
Medicaid Categorically and Medically Needy. Can not "Balance Bill"
Medicaid Eligibility Must be checked monthly
DEERS Computerized database that lists all active and non active service members and their dependants
How is Tricare Managed? By the military
Who is the Tricare Sponsor? The service member
How is Tricare administered? On a regional basis
CHAMPVA If you have Tricare, you're not eligible for CHAMPVA. You can only have one or the other.
Worker's Compensation For those injured on the job.
What does Worker's Comp include? Medical expenses, disability pay, vocational rehab and death benefits
Who pays the Premiums for Worker's Comp? Paid by employer in exchange for employee not suing for injury on the job.
Is worker's Compensation "no fault" insurance? Yes
What are the three parts of Worker's Comp? Disability Pay, Medical Expenses, Vocational Rehab
What insurance program is for the needy? Medicaid
What is the primary goal of managed care and resulting benefit? Lower Costs and Lower Premiums
What are insurance premiums? Payments made to an insurance company in return for benefits
Who pays the insurance premium? The policy holder
Who is ultimately responsible for paying the medical bill? The guarantor
What is co-insurance? Provisions by which the policy holder and insurance company share costs
What is the out-of-pocket expense that must be paid before insurance coverage goes in to effect? Deductible
When should the co-pay be collected? At the time of service
What does the ICD-9-CM identify? Diagnosis
Which Volumes of the ICD-9-CM are used in the physician's offices? Volumes 1 and 2
How is Volume 3 used? To code inpatient services in hospitals
The ICD-9-CM code book is updated every October and we must start using the new book when? January 1st
Before submitting ICD-9-CM codes to an insurance company what form must be filled out? CMS-1500
What is an insurance log used for? To track the status of insurance claims
Which healthcare insurance plans are more expensive? Individual plans
When parents are divorced or separated, which plan is considered the primary plan? The plan of the parent with legal custody
Which types of codes may require modifiers? CPT-4 codes
When multiple modifiers are used, the first modifier is what? -99
When a worker is injured on the job, which type of coverage is provided? Workers' Compensation
Who pays the premiums for Workers' Compensation? The employer in exchange for the employee not suing them for on the job injury
When coordinating insurance benefits for children, what rule determines which parents has the primary insurance? The birthday rule
What is the birthday rule? When both parents have insurance, the parent whose birthday comes first in the calander year has the primary insurance
Are participating providers allowed to "balance bill" Medicaid patients for the cost of treatment over what is reimbursed? NO
What is the computerized data bank that lists all active and retired military service memebers? DEERS
Is the statute of limitations for minors extended in all states until the child reaches legal age? Yes
On what form do we file Medicare claims? CMS-1500
When a patient has coverage from more than one insurance company, what do we call the company that is billed first? Primary Insurance
After a claim form has been processed and payment is sent, what is the document that outlines how payment is made called? EOB-Explanation Of Benefits; For Medicare it is called RA-Remittance Advice document
Who manages Tricare? The military
Can a provider's charges be different from the UCR fees? Yes
What code identifies accidents? E-Codes
What does Medicare part B pay for? Physician Fees, Diagnostic tests and screenings
Who issued the NPI? CMS- The Center for Medicare and Medicaid Services
When preparing OCR scannable claim, what rules follow? All capital letters, No punctuations, MMDDYYY format, no titles
In 1990 what federal act was established that protect the civil rights of disabled individuals? The ADA - Americans with Disabilities Act
The maximum amount a third-party payer will pay? The allowable charge
Why do we use a standardized coding system? To facilitate third party payers
What code describes a condition other than an illness? V-Codes
Where can you find rules and regulations governing health insurance coding? The Federal Registry
List examples of Medicaid Fraud: Billing for brand name drugs when generics drugs are dispensed. Billing for more services than the ones provided. Billing for services not performed. Billing more than once for the same service. Billing separately for services that should be combined.
List preventive services provided by Medicare: BCCDGMPP Bone Density testing, Colorectal Cancer Screening, Clinical Breast Exams, Diabetes Services, Glaucoma Testing, Prostate Cancer Screening, Pap Test, Mammographic Screening
Created by: JDenning8984