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Test 13-17 Reimburse

Review and Quiz

Blue Cross Blue Shield coverage includes the following programs: Fee-for-service Managed care plans Medicare Supplemental plans
An exclusive provider oganization (EPO) is simlar to an HMO
The BCBS PPO plan is a subscriber-driven program
The Federal Employee Health Benefits Program cards contain the phrase Government Wide Service Benefit Plan and employees have identification numbers that begin with the letter: R
Healthcare Anywhere allows members to have access to benefits throughout the United States and world
BlueWorldwide Expat provides medical coverage for employees and dependents who spend more than 6 months outside the United States
When a patient is covered by primary and secondary or supplemental Blue Cross Blue Shield health insurance plans modifications are made to the CMS-1500 claim
Blue Shield was created in 1938 and originally covered physician services
Which of the following is attached when completing secondary claims? A remittance advice
The deadline for filing Blue Cross Blue Shield claims is one year from date of service
The largest single medical benefits program in the United States is Medicare
All Medicare beneficiaries can also obtain a supplmental insurance policy called Medigap
Individuals age 65 or over do not pay a monthly premium for Medicare Part A if they or their spouse paid Medicare taxes while they were working
A benefit period begins with the first day of hospitalization and ends when a patient has been out of the hospital for ________ consecutive days. 60
Persons confined to a psychiatric hospital are allowed ________ lifetime reserve days instead of the 60 days allotted for stay in an acute care hospital. 190
The goal of Programs of All-Inclusive Care for the Elderly is to help people stay independent and live in their community as long as possible
Special incentives mandated by Congress to increase the number of health care providers signing and participating provider agreements with medicare include Direct payment of all claims A 5% higher fee schedule Publication of PAR directory to all Medicare patients
The Medicaid program was implemented in which year? 1965
Which of the following would be covered under Medicaid? Categorically needy Medically needy Special groups
Categorically needy Medicaid eligibility groups are not necessarily entitled to nursing facility services for individuals under the age of 21
Medicaid operates as a ________ payment system. Vendor Fee-for-service
What type(s) of services are exempt from copayments from Medicaid recipients? Emergency Family planning
Dual eligibles refers to individuals entitles to Medicare and eligible for some type of Medicaid services
Blue Shield was created in 1938 and originally covered physician services
Which of the following is attached when completing secondary claims? A remittance advice
The deadline for filing Blue Cross Blue Shield claims is one year from date of service
The largest single medical benefits program in the United States is Medicare
All Medicare beneficiaries can also obtain a supplemental insurance policy called Medigap
Individuals age 65 or over do not pay a monthly premium for Medicare Part A if they or their spouse paid Medicare taxes while they were working
A benefit period begins with the first day of hospitalization and ends when a patient has been out of the hospital for ________ consecutive days. 60
Persons confined to a psychiatric hospital are allowed ________ lifetime reserve days instead of the 60 days allotted for stay in an acute care hospital. 190
Medicaid is always either the Secondary payer Payer of the last resort
Providers receive reimbursement from Medicaid on what type of basis? Lump sum Several claims at once
Special accidental injury rider 100% on nonsurgical care rendered within 72 hours of accidental injury
BlueWorldwide Expat Global medical coverage for employees who work outside the United States
Coordinated home health and hospice care Alternative to acute care setting
BCBS basic coverage benefit Diagnostic laboratory services
Medicare supplemental plans Plans augment Medicare program
Nonprofit corporation Charitable, educational, civic, or humanitarian organization
Medical emergency care rider Immediate treatment sought and received for sudden, severe condition
Healthcare Anywhere Access to health benefits around the world
Exclusive provider organization (EPO) No coverage provided for services outside the network
Hospice Autonomous, centrally administered program of palliative care
Medicare Cost Plan Individual receives health care from a non-network provider; original Medicare plan covers the services
Relative value unit Physician work, practice expense, and malpractice expense
Medicare Savings Account Money managed by a Medicare-approved insurance company
General enrollment period Held January 1 through March 31 of each year
Benefit period Begins first day of hospitalization
Federal Medical Assistance Percentage Portion of Medicaid program paid by the fedreal government
Surveillance and utilization review system Safeguards against inappropriate use of Medicaid services
Payer of last resort Medicaid program
EPSDT (Early and Periodic Screening, Diagnostic, and Treatment Services) Routine pediatric checkups for all children enrolled in Medicaid
Medicaid Medical assitance program for individuals with low income
Mother/baby claim Services provided to a baby under mother's ID number
PACE Alternative care for persons aged 55 or older who require nursing facility level care
Voided claim Deduction from lump-sum payment made to provider
MCCA Prevents married couples from being required to spend down
Dual eligibles Individual entitled to Medicare and Medicaid
Medicare is available to an individual who has worked at least 10 years in Medicare-covered employment, is at least 65 years old, and is a permanent resident of the United States
Upon applying for Medicare Part A and Part B, there is an intitial enrollment period of how many months? 7
The general enrollment period for Medicare Part B coverage is held from January 1 through March 31 each year
A Medicare benefit period begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days
Lifetime reserve days may be used only once during a patient's lifetime and are usually used during the patient's final, terminal hospital stay
The Privacy Act of 1974 allows MACs to release unassigned claim status information to nonPARs as follows: date the claim was received by the payer; date the claim was paid, denied, or suspended; and general reason the claim was suspended.
A Medicare private contract is an agreement between the medicare beneficiary and a physician who has opted out of Medicare for 2 years. This means that the physician cannot bill for any service or supplies provided to any Medicare beneficiary for at least 2 years
The patient has the following health plans: Medicare, Medigap, and an employer large group health plan (EGHP). The billing order for this patient would be EGHP, Medicare, Medigap
Individuals automatically enrolled in Medicare Part A are those who already receive Social Security, Railroad Retirement Board benefits, or disability and are not yet age 65
Under which program does the federal government require state Medicaid programs to pay Medicare Part B premiums, patient deductibles, and coinsurance for individuals who have Medicare Part A, a low monthly income, limited resources, and are not otherwise Qualified Medicare beneficiary
Hospice provides which services for patients? Medical care, as well as psychological, sociological, and spritual care
Medicare Advantage plans include managed care plans and private fee-for-service plans that provide care under contract to Medicare and may include such benefits as coordination of care, reductions in out-of-pocket expenses, and prescription drugs. Medicare Part C
Which Medicare plans provide care under contract to Medicare (in the form of managed care plans and private fee-for-service plans) and may include benefits such as prescription drugs and reductions in out-of-pocket expenses? Medicare Advantage
Which type of account provides a means for individuals without Medicare to set aside money for current medical expenses as well as futuer medical expenses, with the benefit of tax-favored treatment of the funds? Health savings account
Medicare supplementary insurance is also known as Medigap
Which of the following providers are required to accept assignment on all Medicare covered services, regardless of their participating status? Psychologists
Prior to performing an elective procedure or a noncovered procedure on a Medicare beneficiary, a nonPAR must do what? Have the beneficiary sign and date a surgical disclosure notice
The act of billing the patient for the difference between the charged fee and the Medicare allowed fee (which is restricted in many states) is known as: balance billing
An agreement between a Medicare beneficiary and a physician or other practitioner who has opted out of Medicare for 2 years is known as a Medicare private contract
The purpose of the advance beneficiary notice is to alert the patient that a service is unlikely to be reimbursed by Medicare and that the patient must guarantee payment for services
Medicare is considered primary when the patient is also covered by TRICARE
Which is sent to Medicare beneficiaries on a monthly basis that lists health insurance claims information? Medicare Summary Notice
The deadline for filing Medicare claims is December 31 of the year in which the service was provided
How many days must be allowed to pass before a provider can resubmit a paper CMS-1500 claim to Medicare? 45
the Spousal Impoverishment Protection legislation was originally part of Medicare Catastrophic Coverage Act
Medicare beneficiaries with low incomes and limited resources may be eligible for Medicaid benefits; as a result, beneficiaries will receive additional services, not covered by Medicare, such as ambulatory surgery services, emergency department services, and outpatient care
Certain individuals who have resources at or below twice the standard allowed under the SSI program and income at or below 100% of the FPL do not have to pay their monthly Medicare premiums, deductibles, and coinsurnace; they are categorized as qualified Medicare beneficiaries
Medicaid will conditionally subrogate claims when there is liability insurance to cover a person's injuries
Preauthorization guidelines for Medicaid recipients are required for which of the following? Elective admissions and extension of inpatient days
Medicaid provides medical and health-related services for individuals and families with low incomes and limited resources, who are collectively known as medically indigent
The Medicaid program that makes cash assistance available on a time-limited basis for children deprived of support because of a parent's death, incapacity, absence, or unemployment is the Temporary Assistance to Needy Families
Annual income guidelines for the poverty level that affect Medicaid eligibility are established by which government? Federal
The spousal impoverishment protection legislation exempts which items from the couple's combined countable resources? Primary home, household good, automobile, and burial funds
How frequently should a patient's Medicaid eligibility be verified? With each visit to the provider
Relatives or legal guardians who take care of children under age 18, or age 19 if still in high school, are called what by the Medicaid program? Caretakers
The ultimate purpose of th Programs of All-Inclusive Care for the Elderly (PACE) is to help the person maintain independence, dignity, and quality of life
A disproportionate share hospital is one that treats a disproportionate number of what type of patient? Medicaid
States rarely require Medicaid recipients to pay a premium
Each state's annual federal medical assistance percentage is determined by using a formula that compares the state's average per capita income level with the national average
A Medicaid claim that has been corrected, resulting in additional payment(s) to the provider, is what kind of claim? Adjusted
Medicaid remittance advice documents should be maintained for how long? According to the statue of limitations of the state in which the provider practices
The unit in charge of safeguarding the state's Medicaid program against unnecessary or inappropriate use of services it the Surveillance and Utilization Review System
Block 23 of the CMS-1500 claim contains what Medicaid number, if applicable? Preauthorization
What coverage does a Medicaid Baby Your Baby program provide? Prenatal care only for the pregnant mother
An individual who is covered by both Medicare and Medicaid is called a(n): Dual eligible
Which of the following practices is prohibited by law? Balance billing of Medicaid patients
When an enrollee has a primary care provider who authorizes access to specialty care bust is not at risk for the cost of the care provided, the beneficiary is enrolled in a primary care case management plan
The Medicare Catastrophic Coverage Act of 1988 (MCCA) implemented Spousal Impoverishment Protection legislation in 1989 to prevent married couples from being required to do what before one of the partners could be declared eligible for Medicaid coverage Spend down income and other liquid assets (cash and property)
If a service provided can be categorized as both EPSDT and famiy planning, what is entered in Block 24H on the CMS-1500 claim? B
TRICARE is a health care program for active duty members of the military and their qualified family members
The office that coordinates and administers the TRICARE program is called TRICARE Management Activity
Doctors who are assigned to sponsors and who are also part of the TRICARE provider network are called: primary care managers
TRICARE deductibles are applied to the government's fiscal year, which runs from October 1 to September 30
TRICARE beneficiaries are protected from devastating financial loss due to serious illness or long-term treatment through a catastrophic cap benefit that establishes limits over which payment for services is not required
TRICARE Standard enrollees are responsible for paying what as well as copayments? An annual deductible
A registered nurse or physician's assistant who assits primary care managers with preauthorizations and referrals to health care services in the military treatment facility or the civiliam provider network is called a health care finder
A certificate issued by a military treatment facility stating that the facility cannot provide needed care is called what? A nonavailability statement
Which of the following would qualify as a TRICARE sponsor? Retired uniformed service personnel
The function of the TRICARE Service Centers is to assist TRICARE sponsors with health care needs and answer questions about the program
What manages TRICARE programs and demonstration projects? The TRICARE program management organization (PMO)
A comprehensive health care program for which the Department of Veterans Affairs (VA) shares costs of covered health care services and supplies with eligible beneficiaries is called: CHAMPVA
What tests and establishes the feasibility of implementing a new program druing a trial period, after which the program is evaluated, modified, or abandoned? Demonstration project
What system is used to confirm TRICARE eligibility for sponsors and their dependents? Defense Enrollment eligibility Reporting System (DEERS)
Active duty personnel must enroll in what program to receive guaranteed priority access to care at MTFs? TRICARE Prime
The health insurance specialist submits TRICARE claims to TRICARE contractors
If a TRICARE sponsor and spouse divorce, what effect will this have on the TRICARE status of the children? The children remain eligible for TRICARe even if the parents divorce or remarry
How many regions are in the TRICARE system? 4
Decision-making tools used by providers to determine appropriate health care for specific clinical circumstances are known as practice guidelines
Which TRICARE program requires retired military to pay an annual enrollment fee? TRICARE Prime
Who is available to assist providers in recovering charges if a beneficiary fails to pay his or her deductible or cost share (e.g., copayment)? Beneficiary services representative
If the patient is being transferred within the next 6 months, TRICARE suggests that the provider should accept assignment to prevent collection problems
The purpose of the good faith policy established by TRICARE is to allow the provider a means to recover payment when the enrollee has presented an invalid ID card
What special handling is required for all injuries that have been assigned ICD codes in the 800 to 959 range? A Personal Injury-Possible Third-Party Liability Statement should accompany the claim.
Block 31 of the CMS-1500 claim submitted to TRICARE must contain the name and credentials o the provider
The legislation that provides workers' compensation for federal employees is called the Federal Employees' Compensation Act
The quasi-public agency that provides workers' compensation insurance coverage to private and public employers and acts as an agent in state workers' compensation cases involving state employees is called the: State Insurance Fund
The workers' compensation First Report of Injury form is completed when the patient first seeks treatment for a work-related illness or injury
The filing deadline for the First Report of Injury form is determined by state requirements
State compensation boards establish a schedule of approved workers' compensation fees based on what unit value scale? RVS
Providers are required to accept the compensation payment as payment in full; this is called accept assignment
what part of the U.S. Department of Labor administers programs that provide wage replacement benefits, medical treatment, vocational rehab, and other benefits to federal workers or eligible dependents who are injured at work or acquire an occupational ill Office of Workers' Compensation Programs
According to OSHA, comprehensive records of all vaccinations given and any accidental exposure incidences, such as needle sticks, must be maintained for how many years? 20
What is the definition of temporary partial disability? The employee's wage-earning capacity is partially lost, but only on a temporary basis.
What agency can a worker contact to appeal a denied claim? State Workers' Compensation Board
the type of workers' compensation claim that is easiest to process is medical treatment
The person responsible for completing the First Report of Injury is the treating physician
An employee twisted his ankle at work on December 1 and called in sick to work on December 2 and 3. The employee saw his family physician on December 4. The date to be entered in item 4 of the First Report of Injury is December 1
Item 6 of the First Report of Injury form requires the employee's word-for-word description of the accident. if the space in item 6 is not sufficient, what should the provider do? Attach an additional page to the form
A workers' compensation pgoress report is filed when there is any significant change in the worker's medical or disability status
If an employee willfully misrepresents a physical condition to obtain benefits from the state compensation fund, this is an example of employee fraud
What group of government employees is excluded from federal workers' compensation programs? Uniformed services
An employee will lose the right to workers' compensation coverage if the injury results solely from drug or alcohol intoxication
Workers' compensation premiums are paid by the employer
A dispust resolution process in which a final determination is made by an impartial person who may not have judicial powers is known as arbitration
Which of the following entities can be a designated fiscal agent? State Insurance Compensatin Fund
what information is entered in Block 11 of the CMS-1500 claim for a workers' compensation case? The workers' compensation claim number is entered in Block 11 of the CMS-1500
The diagnosis pneumoconiosis is associated with which federal compensation program? Federal Black Lung Program
Workers' compensation laws protect the employer by limiting the award an injured employee can recover from an employer
When an injured employee has suffered a loss of eyesight, hearing, or a part of the body or its use, benefits are payable according to a payment schedule set by law
A participating provider is one who enters into a contract with a BCBS corporation and agrees to bill patients for only deductible and copay/coinsurance amounts
A BCBS program that requires participating providers to adhere to managed care provisions is called a(n) preferred providre network (PPN)
A BCBS special accidental injury rider covers what percentage of nonsurgical care sought and rendered within 24 to 72 hours of the accidental injury? 100
For BCBS to cover care rendered under a medical emergency care rider, the insurance specialist must link diagnoses reported in Block 21 with services reported in Block 24
Which health insurance contract covers company employees who are located in more than one geographic area? Healthcare Anywhere
Which is a BCBS managed care program? Point-of-service plan
A contract between an insurer and a health care provider or group of providers who agree to provide services to persons covered under the contract is called a preferred provider arrangement
Which concept applies when BCBS directly reimburses participating providers for health care services rendered to subscribers? Assignment of benefits
A third-party administrator is a company that provides administrative services to health care plans
A health care system that assumes or shares the financial and health care delivery risks associated with providing comprehensive medical services to subscribers in return for a fixed, prepaid fee is a health maintenance organization
Business entities that pay taxes on profits generated by the corporation and distribute after-tax profits to shareholders and offers are what kind of organizations? For-profit
In exchange for tax relief for any of the nonprofit BCBS plans, the nonprofit plans are forbidden by state law from canceling coverage for an individual based on poor health or if payments to the provider have far exceeded the average
From whom must BCBS plans receive approval before instituting benefit changes or rate increases in each individual state? State insurance commissioner
The BCBS preferred provider network rate is generally how much lower than the PAR allowed rate? 10%
The amount commonly charged for a specific medical service by providers within a particular geographic region is known as the usual, customary, and resonable rate
When a nonPAR agrees to file a claim on behalf of a BCBS patient, the payment is sent to the patient
A speical clause written into a contract that stipulates additional coverage over and above the standard contract is a rider
Whay may occur if a patient neglects to follow the mandatory second surgical opinion requirement of her BCBS plan? The patient's out-of-pocket expenses may be greatly increased.
The customary deadline for filing BCBS claims is how long from the patient's date of service? 1 year
Approximately hw many Americans are covered by a BCBS plan? 80 million
A BCBS preferred provider network requires providers to adhere to what provisions? Managed care
What type of BCBS claims may require forwarding to a third-party administrator? Mental health
Which feature makes a BCBS plan different from other commercial plans? BCBS provides billing manuals and newsletters to keep PARs up-to-date on insurance procedures.
When filing a claim for a patient who is enrolled in the Federal Employee Program, what number is used for the group ID number on the claim? Three-digit enrollment code
For-profit commercial plans have the right to cancel a policy at renewal time if the patient moves into a region of the country in which the company is not licensed to sell. True
For-profit commercial plans have the right to cancel a policy at renewal time if the person is a high user of benefits and has purchased a plan that does not include a non-cancellation clause. True
The first known Blue Shield plan was formed in Palo Alto, CA in 1939 and was called the California Physicians' Service. True
Where did the forerunner of what is known today as Blue Cross begin? 1929 at Baylor University Hospital in Dallas, TX
BCBS fee-for-service or traditional coverage is selected by: Individuals who do not have access to a group plan Many small business employers
Examples of Blue Cross Blue shield coverage plans Fee-for-service (traditional coverage) Indemnity Managed care plans Federal Employee Program (FEP) Medicare supplemental plans Healthcare Anywhere
Examples of managed care plans Coordinated home health and hospice care Exclusive provider organization (EPO) Health maintenance organization (HMO) Outpatient pretreatment authorization plan (OPAP) Point-of-service (POS) plans Preferred provider organization (PPO) Second surgical
BCBS major medical (MM) coverage includes the following services in addition to basic coverage: Office visits Outpatient nonsurgical treatment Physical and occupational therapy Purchase of durable medical equipment (DME) Mental health visits Allergy testing and injections Prescription drugs Private duty nursing Dental care required - injury
Special clauses stipulating additional coverage over and above the standard contract. Riders
Covers 100% of nonsurgical care sought and rendered within 24-72 hours (varies according to the policy) of the accidental injury. Special accidental injury rider
Covers immediate treatment sought and received for sudden, severe, and unexpected conditions that if not treated would place the patient's health in permanent jeopardy or cause permanent impairment or dysfunction of an organ or body part. Medical emergency care rider
Offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed healthcare provider Indemnity coverage
Allows patients with this option to elect an alternative to the acute care setting. Coordinated home health and hospice care
Similar to a health maintenance organization that provides healthcare services through a network of doctors, hospitals, and other healthcare providers, except that members are not required to select a PCP and they do not need a referral to see a specialis Exclusive Provider Organization (EPO)
A primary care provider (PCP) can also be known as: A personal care physician or personal care provider
Requires preauthorization of outpatient physical, occupational, and speech therapy services. Outpatient pretreatment authorization plan (OPAP)
Allows subscribers to choose at the time medical services are needed, whether they will go to a provider within the plan's network or outside the network. Point-of-service (POS)
When subscribers go outside the network for health care, they must obtain the approval of the PCP and the costs are lower. False
Offers discounted healthcare services to subscribers who use designated healthcare providers (who contract with the PPO) but also providers coverage for services rendered by healthcare providers who are not part of the PPO network. Preferred provider organization (PPO)
Subscriber member
Necessary when a patient is considering elective, nonemergency surgical care. Second surgical opinion (SSO)
An employee-sponsored health benefits program established by an Act of Congress in 1959. Federal Employee Health Benefits Program (FEHBP)
Allows the participating BCBS plan members who are temporarily residing outside of their home HMO service area for at least 90 days to temporarily enroll with a local HMO. From Home Care Program
What is the most common coinsurance amount? 20 or 25%
The amount commonly charged for a particular medical service by providers within a particular geographic region for establishing their allowable rates. Usual, customary, and reasonable (UCR) basis
Claims not paid within ________ days must be rebilled. 30
Some mental health claims are forwarded to a ________ ________, a company that providers administrative services to healthcare plans and specializes in mental health case management. Third-party administrator (TPA)
Don't worry about photocopying the front and back of all patient ID cards because they stay the same. False
Claims for BlueCard patient with more than one insurance policy must be billed directly to the plan from which the program originated using what form? CMS-1500
Created by: adale3171