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CRCR

CRCR study

QuestionAnswer
ERA Electronic Remittance Advice
Level 1 of ERA Receipt of Data/the information is printed
Level 2 of ERA Electronic remittance is received, entered into computer, and viewed at terminal
Level 3 of ERA Electronic remittance is received, entered into computer - remittance data are electronically posted by the patient accounting software, updating the patients account.
Level 4 of ERA Total automation receipt, data entry, payment posting, adjustment processing
EFT is the electronic transfer of funds from payer to payee thru the banking system (fasted way to move money)
SNF Services Covered (6) Room and board, PT, OT, ST, Respiratory Carem Drugs, Blood transfusions, supplies and equipment
EDI Electronic Data interchange
EDI used for? translating, standardizing and sending transactions electronically (claims) 837. 270/271, etc...
835 Remittance
Violation of the DRG Window (3 day) causes delay in billing, rejection of claim, additionaly sanctions, fines, revocation of medicare status
UBO4 is used for institutional providers(List 4) hospitals, hospice, rural health clinic, snf
SNF IP rules must be IP atleast 3 days before discharging to SNF, must be admitted with in30 days of IP stay.
DRG used for Inpatient billing
APC used for outpatient billing
Benefit SNF Period? 100 Days during a benefit period/ Benefit period ends during which the patient is not a IP or SNF for 60 days.
CCI Edits are? Program consists of Edits implemented w/claim processing to catch errors before sending out
Package Pricing is? payment system in which a lump sum or bundled payment is negotiated between payor and some or all providers.
Site of service limitation? health plans developed care plans for common disease and procedures and must happen in approved setting
Title 804 governs actions of skip tracing
Title 805 Collector communication ceasing communication
Title 806 proibits harassment abuse from the collector
Title 807 deceptive or false representations
Title 604 (FCRA) gives permision to see credit reports by court, by consumer, and a reporting agency who has legitimate business to view
Hospice Benefits with Medicare include 2 90 day periods and unlimited subsequent periods-60 days each
CMS 1500 is used by non institutional providers such as physicians, allied health professions, CRNA, home health agency's and Medical Equipment suppliers
What is EFT balancing and Control Use of EFT greatly simplifies cash balancing and control requirements. The bank notifies the provider of amount received and issues deposit. The provider balances this to the ERA received.
Common Provision found in manage care contracts for protection for medical expense that exceed certain levels. STOP LOSS Protection
Per Diem payment fixed daily payments that do not vary based on level of services/IP
Percentage Discount is where the provider accepts a percentage discount from total charges.
Most common contracted payment models (7) Percentage discount, DRG, APC, Case Rate, Per Diem, Package Pricing, Capitation
Method of payment to healthcare providers whereby a FIXED amount is paid per ENROLLEE to cover defined set of services over a specifica period of time Capitation
The difference between providers charges and the insuracne payment that are written off the patients account as... Contractual allowance
The first critical step for all patients arriving for service scheduled or unscheduled is verifying patients identity with 2 forms...list ID, name, DOB, SSN
Time of Service Denials include new technology used without determining coverage(3D), charges bundled/unbundled incorrectly, accuity level changes but pt type does not change, admission notification not done, Pt IP but should be OBs, test performed not ordered, invalid HPCPS coding
Post Service Denials include late charges, 2 claims with DOS that overlap, untimely filing
Pre Service Denials include No Pre Auth, clinicals not called for certification, INS not verified, Inaccurate Data entry, Copying registration without verifying
CLIA Clinical Laboratory Improvemen Act
APC only covered under medicare part B
Impacts of Denials besides loss of reimbursement and additional cost Productivity(staff reworks files), patient loss of confidence, employee frustration increased(morals affected)
Onsite self pay is enhanced by the ability to accept these forms of payment Cash, Credit, check or debit cards
Liability payers include Auto, Work Comp, Premises for medical coverage under property cases
Healthplan process claim from reimbursement and subsequently pursues payment from liability payer is... SUBORGATION
Medicare allows providers to submit liability claims after this waiting period 120 days.
Claim against personal property that secures payment of a debt Lien
CWF Common Working File
Medicare has 2 types of appeals to charges Beneficiary appeal and Provdier appeal
Second Placement accounts are an agency accepting assignment of returned or cancelled debts from initial collection agency.
Title VI is called Fair Credit Reporting Act
The truth and lending act is Title I- established rules for consumers credit and sales and loans
Medicare will try to collect self pay portions for how many days? 120 days then goes to collections agency
For an acount to be considered bad debt collection must have been attempted and documented T/F True
Payment floors for IP claims 13 days electronic/26 for paper claims
MR Medical Record
MPI Master Patient Index
CPI Corporate Patient Index
Critical patient information collected when scheduling are used as identifiers(list 4) Legal name, DOB, sex, SSN
DME examples Wheelchairs, hospital beds, oxygen tanks
Homebound patients requiring periodic skilled nursing and therapeutic care ordered by physician Home Health Care
Patients with incurable disease and have a life expectency of six months or less Hospice Care
Orthopedic surgical patient that require intense PT/stroke PT who require comprehensive Rehab Skilled Nursing Patients
Can you use a ABN for a IP stay NO
When is a ABN required when a test or service does not meet medical necessity according to LCD/NCD
Credit balances are created by posting errors, billing errors, payment errors, hospital and payer system limitations
Chargemaster issues can result in inappropriate reimbursement
Claim rejection is a claim rejected for a # of reasons (list some) inability to identify patient, ineligibility of pt, noncompliance of the provider with billing requirements.
Medicare Claims must be filed within what qualifying time limit? 1 year
Types of unscheduled patients (6) Emergency, urgent inpatients, routine walkins outpatients, ED outpatients, obs patients, Newborn
3 types of schedule patients Scheduled IP, Scheduled OP, reaccuring/series
Enrollment and disenrollment of a healthplan transanction set 834
What must appear on the ABN? (5 items) Service physician ordered, cost, date of service, non coverage reason, financial responsibility
Capitation Contract Payment Method is provider received a flat fee every month for taking care of individual
Case Rate Contract Patyment Method is specific condition forms the basis for establishing a single payment for all services(colonscopy)
Financial counseling payment options Full payment proir to service, short term payment plan, bank loan
Underpayment denial payer does not pay the agreed contract(Aetna) amount to provider(LUH)
Technical Denial Demographic error, imcomplete insurance 411, no precert or auth, no contunied stay auth, exceeds frequency limit(pt visits)
Clinical Denial not medically necessary, diagnosis and cpt do not match, carve out days, inappropriate level of care, HCPCS incorrect for procedure
Bankruptcy Chapter 7 Straight- involuntary or voluntary
Chapter 11 debtor reogranization (court supervised plan) within 120 days
Chapter 13 Rehabilitation- does not liquidate-looks for future earnings
By siging a contractual agreement(aetna, cigna etc) the facility becomes In network
Rural Hospitals with fewer than BLANK beds can be reimbursed by Medicare 100 (often use of swing beds)
Patient discharged status code 03
837 transaction set coordination of benefits
835 transaction set claim payment/remittance advice
277/278 transaction set referral certification and authorization
820 transaction set healthplan premium payments
Created by: Copa