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UNDER BROAD FEDERAL GUIDELINES
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PAYER OF LAST RESORT
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Medicaid Test Review
| Question | Answer |
|---|---|
| UNDER BROAD FEDERAL GUIDELINES | medicaid programs vary form state to state |
| PAYER OF LAST RESORT | medicaid is known as the payer of the last resort because in the presence of any other health coverage, Medicaid must be billed last. |
| TRUE | (TRUE OR FALSE) Medicaid can be billed only if the other coverage denies responsibility for payment, if it pays less than the Medicaid fee schedule, or if Medicaid covers procedures not covered by other policy thus all additional health and liability. |
| MEDICAID ELIGIBILITY | medicaid is a government assistance program designed to help individuals with medical expenses. |
| TRUE | (TRUE OR FALSE) Medicaid is state administered and federally mandated |
| TANF | Temporary Assistance for Needy Families (used to be called AFDC). Provides time-limited cash assistance for children deprived of support because of parent's death, incapacity, absence, or unemployment. |
| SSI | supplemental security income |
| Individuals classified as medically needy | can have out of pocket expenses. |
| QMB | Quilified Medicare Beneficiaries |
| QWDI | Qualified working disabled individuals |
| If meet income reguirements do not have to pay | Medicare Part A premiums |
| QI | Qualifying individuals |
| SLMB | Specified low-income medicare beneficiary |
| SLMBs do not have to pay | Medicare Part B premiums |
| SCHIP | State childrens health insurance program |
| Presumptive eligibility | benefit that allow individuals to be enrolled in medicaid for limited time before full medicaid applications are filed and processed. |
| What allows immediate access to services for children who are eligible as well as woman who are in need of treatment for breast or cervical cancer, Eligibility is part of the CDC's national breast and cervival cancer early detection program? | Presumptive eligibility |
| SCHIP | will provide eligivle children with coverage until the age of 19. |
| Spousal Impoverish Protection | Community spouse -spouse residing at the home |
| Community spouse | spouse residing at the home |
| Medicaid Services | EPSDT |
| EPSDT | Early and periodic screening, diagnosis, and treatment |
| Family planning services and supplies | (for mandatory eligibility group) |
| TRUE | (TRUE OR FALSE) Family planning services and supplies (for mandatory eligiblility group) |
| All nonemergency hospitalizations must be | preauthorized |
| To request information about the local medicaid program the insurance specialist should contact the | local county government |
| Dual eligible | When an individual has both medicare and medicaid coverage, covered services are paid by medicare first |
| Participating Providers | any provider who accepts a medicaid patient must accept the medicaid-determined payment as payment in full |
| Medicaid elgibility verificaton system | eligibility is determined for medicaid recipients with MEVs or REVs |
| TRUE | (TRUE OR FALSE) Eligibility should be verified at each encounter |
| Three ways a payer can cerify medicaid eligibility are: | -point-of-service device -computer software -automated voice response |
| TRUE | (TRUE OR FALSE) The federal government mandates that medicaid remittance advice forms are to be kept by providers for a period set by the state in which they practice. |
| Voided claim | is one that medcaid should not have orginally paid and results in a deduction from the lump-sum payment provider |
| A claim that has had a payment correction is an | adjusted claim |
| Utilization Review | A sample of medicaid recipients is sent a monthly survey letter requesting verification of services paid the previous month on their behalf to help verify receipt of medicaid services. |
| Billing notes | Medicaid reimbursement information sent to the provider is called remittance advice |
| TRUE | (TRUE OR FALSE) Medicaid reimbursement information sent to the provider is called remittance advice |
| Four out-of-pocket expenses that medicaid patients may be required are: | -Co-payments -Deductibles -Non-covered services -Monthly premiums |
| FMAP | Federal medical assistance percentage |
| The Mother/baby claim | is used for services provided to a baby and submitted under the motyher's medicaid identification number. |
| What claim is used for coverage is usually limited to the baby's first 10 days of life, and during that time an applicaton must be filed so the baby is assigned his/her own identification number. | Mother/baby claim |
| Medicaid eligibility for infants born to medicaid-elgible pregnant woman can | continue throughout the first one year of the infant's life. |
| When filing an medicaid secondary claim, | the remittance advice from the primary payer may need to be submitted as proof of payment or nonpayment |
| If patient has Medicaid and TRICARE, | TRICARE is billed first |
| TRUE | (TRUE OR FALSE) The federal government mandates that medicaid remittance advice forms are to be kept by providers for a period set by the state in which they practice. |
| Balanced billing the patient the difference between the charged amoutn and the allowed amount is | NOT acceptable |
| Individuals classidied as medically needy MAY have | out-of-pocket expenses |
| Mandatory Federal Eligibility Requirements for Medicaid (1-3 of mandates) | 1. Individuals who meet requirements of TANF program. 2. Children under the age of six and pregnant women whose family income is at or below 133% of the federal poverty level. 3. Supplemental Security Income recipients. |
| Mandatory Federal Eligibility Requirements for Medicaid (4-5 of mandates) | 4. Indiciduals and couples living in medical institutions who have a monthly income up to 300% of the SSI income. 5. Caretakers (relatives or legal guardians who take care of children who are under age 18 or 19 if still in school). |
| Define payer of last resort | medicaid is known as payer of last resort because in the presence of any other coverage, Medicaid must be billed last. Medicaid can be billed only if the other coverage denies responsibility for payment. |
| Three ways to verify eligibility | 1. Point-of-point device 2. Computer software 3. Automated voice response |
| What procedure is used to verify receipt of medicaid services | a sample of medicaid recipients is sent a montly survery letter requesting verification of services paid the previous month on their behalf to help verify receipt of medicaid services |
| Define presumptive eligibility | benefit that allows indivduals to be enrolled in medicaid for a limited time before full medicaid applications are filed and processed. This allows children who are eligible for SCHIP and woman in need of treatment for breast or cervical cancer. |
| Discuss use mother/baby claim | used for services provided to a baby and submitted under the mothers medicaid identification number. Coverage is usually limited to the babys first 10days of life and during that time application must be filed so baby is assigned own identification number |
| Four out-of-pocket expenses that medicaid patients MAY have to pay | 1. Co-payments 2. Deductibles 3. Non-covered services 4. Monthly premiums |
| List 5 Mandatory federal eligibility requirements for medicaid (1-3) | 1. Idividuals who meet requirements of TANF programs 2. Children under the age of 6 and pregnant women whose family income is at or below 133% of the federal poverty level 3. Supplemental security income recipients |
| List 5 Mandatory federal eligibility requirements for medicaid (4-5) | 4. Individuals and couples living in medical institutions who have a monthly income up to 300% of the SSI income. 5. Caretakers (relatives or legal guardians who take care of children who are under age 18 or 19 if still in school) |
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