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UHI 3 & 15

Side A

primary care physician PCP
sate children's health insurance program SCHIP
healthcare effective data & information set HEDIS
point of service POS
health maintenance organization HMO
preferred provider organization PPO
managed care organization MCO
Medicaid Eligibility Verification System MEVS
flexible spending account FSA
early and periodic screening, diagnostic, and treatment services EPSDT
health savings account HSA
second surgical opinion SSO
what is MCO responsible for health care of enrollees & reimbursement to physicians
Medicaid payer of last resort
mother baby claim baby under mother for 30 days
computer/website, POS drive, telephone 3 ways to verify Medicaid coverage
coinsurance, deductible, spin down 3 things you may be required to pay with Medicaid
every time Medicaid should be verified
remittance advice physician reimbursement form
federally mandated & state administrated Medicaid is
dual eligibles Medicare & Medicaid eligible
19 Must be under what age for SCHIP
gatekeeper PCP for essential health care services at the lowest possible cost
2 year children are eligible for Medicaid for
adjusted claim a claim that has payment corrections
Medicare pays before Medicaid
voided should never have been filed
low income, categorically needy, medically needy, special groups, children under 6 Medicaid eligible individuals
Aged, blind, disabled, mental institution SSI recipients eligible for Medicaid
6 months timely filing for Medicaid
PACE (program for all-inclusive care for the elderly age 55 and over who require a nursing level facility care
payer of last resort Medicaid is always
balanced billing physicians can't bill patient if a balance is owed
preauthorization required elective inpatient admission, emergency inpatient admission, more than 1 preoperative day, outpatient procedures, days exceeding state hospital stay limitation, extension of inpatient days
quality assurance program includes activities that assess the quality of care provided in a health care setting
enrollees subscribers (policyholders) is another name for
fee-for-service re
capitation provider accepts preestablished payments
gag clauses prevents providers from discussing all treatment options with patients
Created by: Stacey_Gantt5



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