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Fordney chptr 12

study guide

QuestionAnswer
What are the requirements for disabled individuals to receive medical benefits? Must be disabled for no less than 12 months, & must receive disability benefits for 24 months before Medicare benefits begin.
What are the requirements to receive Medicare Part B? Individual(or their family) must already receive Social Security or Railroad Retirement Benefits, be age 65 or older, handicapped, kidney donor, or in end stage renal failure.
What age is an individual eligible to receive Medicare benefits? At any age, so long as the patient meets with the criteria.
How are benefits payed for in Medicare Part B coverage? Through an annually increasing basic premium.
Are immigrants eligible for Part A & B coverage? Yes, if they have resided in the U.S. for 5 years or more.
How do employers contribute to Medicare Part A services? Through monthly premiums.
How long is a benefit period? From the first day you enter a hospital/NSF until no treatment is received for 60 consecutive days.
Is there a limit to how many benefit periods an individual can have? No, benefit periods are unlimited.
What is supplementary medical insurance? Insurance designed to help cover costs of medical care that are not covered by an individual's primary insurance.
Where do funds for Medicare Part B come from? Through those who sign up for benefits, & federal government funded programs equally.
What services does Medicare cover for a chiropractor? Manual manipulation for subluxation(a slight misalignment of the vertebrae of the spine).
Is a physical a covered benefit under Medicare? Yes, an annual physical is covered under Medicare.
What are the state to state policy for Medigap? They are the same for basic benefits, with some states varying in policy types.
Do patients with HMO need supplementary policies? Only if receiving care from out of network providers and want to avoid out of pocket expenses.
When patients choose a Medicare Senior Plan, do they forfeit their medicare card? No, they do not forfeit their Medicare card.
When patients choose an HMO plan, are they required to stay with that plan for a year? No, they do not have to remain with it for a calendar year.
Do non-par physicians have the option to accept Medicare patients? Yes, on a case by case basis.
Can non-par physicians charge any fee they choose? No they may not charge any fee they choose.
Are Medicare reimbursement policies consistent nationwide? No, reimbursements are not consistent nationwide.
Who handles Medicare Part B payments? The patient handles the payments for Medicare Part B.
Another name for a fiscal intermediary is? MAC (Medicare Administrative Contractor).
What does Signature On File mean? The patient has signed authorization papers in their file, updated annually.
Is a patient's signature required on all CMS claim forms? No, signature on file is sufficient.
What is the time limit on professional claim forms? 12 months.
Does Medicaid pick up the balance on Medi/Medi claims? No Medicaid does not pick up the balance on Medi/Medi claims.
For Medigap claims, does Medicare automatically transmit claims to Medigap? Yes, if Medigap information has already been provided.
Where do Medigap claims go to? Private insurance companies.
What is Remittance Advice? Document detailing services billed & payment determination issued to providers.
Who runs the Medicare Part A program? The Centers for Medicare and Medicaid Services.
Is Medicare a federal program? Yes, Medicare is a federal program.
What does Medicare Part A cover? Inpatient care, such as hospital stays, & hospice care.
What does Medicare Part B cover? Outpatient care, such as doctor visits & diagnostic tests.
When does the benefit period for Medicare Part A end? After discharge & 60 consecutive days have passed without any medical care.
What is the current annual deductible for for medicare Part B? $104.90
Are preventative care mammograms covered by Medicare? Yes preventative care mammograms are covered by Medicare, for women 40 & over, once a year.
How often can Medicare be charged for pap-smears? Once every 24 months if low risk, once every 12 months if high risk.
What does Medigap insurance cover? Health care cost that are not covered by Medicare plans until deductible is met.
What is the name for supplemental plans covered by the employers? MSP(Medicare Secondary Payer).
What does Senior HMO cover that Medicare does not? Eyeglasses & prescription drugs.
What program contracts with CMS to review for medical necessity? Quality Improvement Organization (QIO).
What percent does Medicare generally agree to pay? Most commonly 80%.
What is the negotiated amount based on? Total amount billed.
In the Medicare program, what is a mandatory assignment in benefits covered? Surgery performed in the physician's office.
What is a Medicare prepayment screen? Identifies claims to review for a medical necessity & monitor the number of times billed for such procedures during a specific time frame.
When a patient signs an ABN, what modifier is used? HCPCS Level II modifier "GA"
What is a perspective payment system? Hospitals treating Medicare patients are reimbursed according to pre-established rates of illnesses based on diagnosis.
What are payments to hospitals classified as? D.R.G.s, diagnosis-related groups.
What is the Omnibus Reconciliation Act? In the case of a current/former employee or dependent younger than 65, & eligible for Medicare solely because of ESRD, the employer's group coverage is primary for up to 30 months.
What level are alpha-numeric HCPCS codes? Level 2.
What is a fiscal intermediary? Organization under contract to the state to process claims for a Medicaid program, for hospitals, nursing facilities, home health agencies, long term care facilities, and intermediate facilities.
What do the letters after the medical ID numbers on the medicare card stand for? The status of the individual.
What does the letter "D" stand for on Medicare Part D plan? Widow status.
Created by: MAAs_rock