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Medical Insurance 2

week two

A major innovation that made the process of health insurance claims submission simpler was the development of a universal form
The front side of the CMS-1500 claim form is printed in OCR scannable red ink
The most common format used for text files in computers and on the Internet is? ASCII
OCR formatting rules specify? All entries in uppercase, no punctuation, MM/DD/YYYY birth date format
A small provider of services is one with less than? 25 full-time equivalent employees
The patient information form is considered a legal document and should be updated no less often than? once a year
A patient's name, address, Social Security number, and employment data are commonly referred to as? Demographic information
An individual covered under Medicare is referred to as a? Beneficiary
An insurance policy that covers an individual, his or her spouse, and eligible dependents is referred to as a? Family plan
A multipurpose form used by most medical practices for billing is called a? Encount form, Superbill, and Routing form
In noncomputerized practices, patient charges and payments can be tracked manually on a? Patient ledger card
The CMS-1500 claim form has______ separate blocks? 33
After the health insurance professional has completed the claim form, it shouod be? Proofread
An example of a method for manual claims follow-up is using an? Insurance log and Insurance register
A company that receives claims, consolidates them, and transmits them in batches to third party payer is called a? Clearinghouse
Name the two major sections of teh CMS-1500 claim form Patient/Insured info and Physician/supplier info
List the situations when a space is required instead of the usual punctuation or symbols in OCR formatting Date of birth, area code, social security number, and money
The type of health insurance that offers the most choices of providers, in which patients can choose any provider they want and can change providers at any time is? Indemnity plan or FFS plan
An example of a third-party payer is? A commercial insurance company, Blue cross and Blue shield, Medicare Medicaid
Group insurance typically is? A contract between an insurance company and an employer
They type of insurance that comprises a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, but quality, service is? Managed care plan
The best type of healthcare plan is? No one type is universally the best
Most FFS plans include the patient paying a? Periodic payment(premium), yearly deductible, and Per-visit coinsurance
The typical levels of coverage in an FFS plan include? Basic/major medical/comprehensive
The amount of money the policyholder has to pay out-of-pocket for any one incident or in any 1 year is limited by? Insurance cap
When the fee charged by a provider falls within the parameters of the fee commonly charged for that particular service within a specific geographic area, it is said to be? Reasonable and customary
A provider who signs a contractual arrangement with a third-pary insurance contractor and agrees to accept the amount paid by the carrier as payment in full is referred to as a? Participating provider (PAR)
The government health insurance program that provides coverage for its own civilian employees is called? Federal Employees Health Benefits Program (FEHB)
When the employer-not an insurance company-is responsible for the cost of its employees' medical services the employer has a? Self-insured program
The federal law designed to protect the rights of beneficiaries of employee benefit plans offered by employers and that sets minmum standards for pension plans in private industry is called? Employee Retirement Income Security Act(ERISA)
A person or organization that processes claims and performs other contractual administrative services is commonly referred to as a? Third-party administrator(TPA)
Name four basic types of plans? FFS, preferred provider organization(PPO), point-of-service(POS), health maintenance organization(HMO)
List three out-of-pocket costs that are standard for patients to pay with FFS plans? Periodic payment health insurance policy premium, yearly deductible, and coinsurance
List four functions commonly performed by TPAs and administrative services organizations Planning, Marketing, human resources management, financing and accounting
Explain what a "carve out" is and give an example? eliminating a certain specialty of health service from coverage. Mental health services
An organized, interrelated system of people and facilities that communicate with one another and work together as a unit is commonly referred to as a? Network
Individuals belonging to a managed healthcare plan are referred to as? Enrollees
The two most common types of MCOs are? Health Maintenance Organization (HMO)s and Preferred Provider Organization (PPO)s
a specific provider who oversees an HMO member's total healthcare treatment is called a? Primary care physician (PCP)
The amount of money a patient has a pay out-of-pocket per visit is referred to as a? Copayment
When an individual first enrolls in an HMO, he or she chooses a? Primary Care Physician (PCP)
Most managed healthcare plans emphasize? Preventive healthcare
A multispecialty group practice where all healthcare services are provided within the building owned by the HMO is called? Staff model
An HMO that contracts with independent, multispecialty physician groups that provide all healthcare services to its members and usually share the smae facility, support staff, medical records, and equipment is called? Group model
A reimbursement system in which healthcare providers receive a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses, is called? Capitation
A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non-HMO patients, but maintain their own offices and identites is called? Open-panel Individual Practice Association (IPA)
a plan that allows patients to use the HMO provider or go outside the plan and pay a higher copayment and deductible is a? Point of Service (POS) plan
a system designed to determine the medical necessity and appropriateness of a requested medical service, procedure, or hospital admission prior, concurrent, or retrospective to the evernt is called? Utilization
If a particular medical service or procedure is determined not to be "medically necessary." a patient may file a? grievance
a procedure required by third-party payers that requires permission before a provider can carry out specific procedures and treatments is? Preauthorization
An MCO typically performs three main fuction, what are they? Sets up contracts and organizations of the healthcare providers, establish the list of covered benefites need to manage core rules, and oversee the healthcare they provide.
Explain what managed care PPO is? it is a network of healthcare providers
explain what managed care HMO is? porvides basic healthcare for a fixed price and a given period.
explain what managed caer IPA is? healthcare is provided by individual healthcare providers
explain what managed care POS is? it is a hybrid allows providers to uses HMO or go outside of it
Under the Federal HMO Act, an entity must have three characteristics to call itself an HMO? an organized system providing healthcare, agreed on set of basic and supplemental health maintenance and treatement services and a volinutarily eenrolled group of people.
Title XIX of the Social Security Act of 1965 established? Medicaid
Medicaid is administered by? CMS
Supplemental Security Income (SSI) is a cash benefit program controlled by? The Social Security Administration
Categorically needy individuals typically include? Low-income families with children, Individuals receiving SSI, Pregnant women, infants, and children with incomes less than a specified percent of the federal poverty level (FPL), and Qualified medicare beneficiaries (QMB)
the term used for the process of depleting private or family finances to the point where the individual/family becomes eligible for Medicaid assistance is? Spend down
The program that provides comprehensive alternative care for noninstitutionalized elderly who otherwise would be in a nursing home is known as? Program of All-inclusive care for the elderly
Medicaid coverage should be verified? Every time a patient comes to the office.
Aged or disabled individuals who are very poor are covered under the Medicaid and Medicare programs, which are commonly referred to as? Dual eligibles and Medi-Medi
Medicare beneficiaries who qualify for certain Medicaid benefits if they have incomes below the Federal Poverty leve (FPL) and resources at or below twice the standard allowed under the SSI program are known as? QMBs
When one state allows Medicaid beneficiaries from other states to be treated in its medical facilities this exchange of privileges is referred to as? Reciprocity
List some of the services that categorically needy individuals must be provided with according to federal standards? Inpatient hospital services, prenatal care, vaccines for children
What is a FI fiscal intermediary
What does a FI do? Processes claims for medicaid
Medicare was established by Congress in 1966 to provide financial assistance with medical expenses to? people older than 65, people with end-stage renal disease, people younger than 65 with disabilities.
Medicare requires its beneficiaries to pay premiums, deductibles, and coninsurance, which is referred to as? cost sharing
Medicare Part A, the hospital insurance part of Medicare, is funded through taxes witheld from employees wages and taxes paid by employers
Coverage requirements under medicare state that for a service to be covered, it must be considered? Medically necessary
Part A coverage is available free of charge to eligible Medicare beneficiaries who? Are eligible to receive Social Security benefits
A private organization that contracts with Medicare to pay Part A and some Part B bills and determines payment to Part A facilities is called a? Fiscal Intermediary (FI)
Medicare part B helps pay for? Medically necessary physician's services
Medicare pays for what percentage of allowable charges after the annual deductible is met? 80%
Managed Healthcare plans that offer regular Part A and Part B medicare coverage and additional coverage for certain other services are called? Medicare part C
The prescription drug coverage plan, which began in January 2006 is called? Medicare Part D
What is a Donut Hole The period during which a Medicare beneficiary is responsible for all prescription durg expenses until a total of $3850 is spent out-of-pocket.
An individual qualifying for Medicare and medicaid benefits is referred to as? Dual eligible
The program that provides community based acute and long-term care services to Medicare beneficiaries is called? Program of All-inclusive Care for the Elderly (PACE)
A health insurance plan sold by private insurance companies to help pay for healthcare expenses not covered by Medicare is called? Supplemental policy
The term used when another insurance policy is primary to Medicare is? Medicare Secondary Payer (MSP)
Some Medicare health maintenance organization (HMO) enrolles are allowed to see specialists outside the "network" without going through a primary care physician. This is called? Self-referring
a group of medical providers that skips the insurance company middleman and contracts directly with patients is? Provider sponsored organization
Local medical review policies (LMRP) were replaced in 2003 by? Local coverage determinatins (LCD)
a form that Medicare requires all healthcare providers to use when Medicare does not pay for a service is? Advance Beneficiary Notice (ABN)
The program that provides community based acute and long term care service? Program of all-inclusive care for the elderly
a health insurance plan sold by private insurance companies to help pay ofr expenses not covered by Medicare? Medigap
the time period Medicare allows for enrolling in a Medicare supplement plan without penalty? Open enrollment
the term used when Medicare is not the primary payer, and the beneficiary is covered under another insurance policy? MSP
the individual responsible for initial MSP development activities formerly performed by Medicare FIs and carriers? COB contractor
List the various managed care choices included under Medicare Part C? Preferred provider organizations(PPO), Provider sponsored organizations(PSO), private fee-for-service(PFS)and Medical saving account (MSA)
TRICARE's tow main objectives are? Accessibility and affordability
TRICARE is administered regionally, serving ______ separate regions? 3
Each region is headed by an individual who is responsible for oversight of all healtthcare delivery activities within his or her region and is called? Regional director
The name of the total healthcare system of the US uniformed services is? Military Health System
TRICARE is administered by? The Department of Defense
The main purpose of the TRICARE Management Activity (TMA) is to? Enhance the performance of TRICARE worldwide.
The computerized data bank that lists all active and retired military service members is called? DEERS
Similar to Medicaid and Medicare, TRICARE-eligible individuals ae referred to as? Beneficiaries
The fee-for-service option offer by TRICARE, which has basically the same benefits as the original CHAMPUS program is? TRICARE Standard
The TRICARE option simialr to perferred provider organization-type managed care is? TRICARE Extra
CHAMPVA is managed by? the VA's HAC
CHAMPVA eligibility can be lsot if certain demographic changes occur, such as? Medicaid and CHAMPVA supplemental insurance
the dealine for filing miltary claims is? 1 year
the annual catastrophic cap for CHAMPVA is? $3000
The service member, whether in active duty, retired, or deceased, is called? sponsors
Explain the purpose of a nonavailability statement? something that is not covered by the on base hospitals and so you must go off base.
Workers' compensation got its start in the 1800s in? Germany
In workers' compensation insurance, the premiums are paid by? The employer
the federal program that establishes worker's compensation for nonmilitary federal government employees is known by the acronym? FECA
the federal program that establishes workers' compensation for railroad workers engaged in interstate commerce is known by the acronym? FELA
an individual responsible for investigating and resolving workers' complaints against the employer or insurance company that is denying the benefits is called? Ombudsman
the time limit for filing a workers compensation claim is established by? Individual state statutes
an injury or illness that is job related typically must be reported to the employer? time limits vary from state to state
a patient's inability to perform normal job duties at the previous level of expertise as a result of being absent from work is called? job deconditioning
after the initial attending physician report has been filed, periodic updates must be provided to the employer/insurer, called? progress report and supplemental reports
The type of insurance that replaces a portion of earned income when an individual is unable to perform the requirements of his or her job because of non-job related injury or illness is called? Disability insurance
the maximum amount of benefits that can be received in a specific time period is called? a benefit cap
the federal act established in 990 that protects the civil rights of individuals with disabilities is called? americans with disabilities act (ADA)
The examining body that determines if an applicant qualifies for SSDI is the? State Disability Determination unit
The method of determining whether or not an individual is eligible for SSI benefits is through a? Financial means test
What is no-fault insurance? benefits are paid to injured workers regardless of who is to blame
List the four major benefit components to workers' compensation? Medical expense, disability pay, vocational rehabilitation, and death benefits
List the physician's two distinct roles in workers' compensation claims? diagnose and treat and provide claims administrations opitions to specific medical and legal questions
List five pertinent items the attending physician's statement must include when filing a disability claim? The diagnosis, the first day the individual was unable to work, wether or not the illness or injury was work related, the nature of the treatment, and restrictions and limitations of the individual
List the nine federal disability programs? SS disability insurance, supplemental security income, medicare, medicaid, workers' compensation, black lung, VA disability compensation program, VA pension programs, VA health services program
Name the two criteria an individual must meet to become eligible for SSDL? worked enough SS coverd work quarters and severe impairment that makes them unable to work
List the three ways disabled individuals can receive SSDL on their own as disabled workers, widows or widowers who are 50 to 65 of insured individuals and adults 18 to 65 who become disabled in childhood whose parents recieved SSDL
What are the parts of Medicare and what do they cover Part A-hospital insurance, Part B-Medical(physicians' care), Part C-(Medicare Advantage plans) Manged care-type plans, Part D-Prescription Drug Plan
Created by: Seanmorrone
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