Question 1

additional documentation request (ADR)

Accepted Answer

A communication from a Medicare Program Review contractor that asks for more information regarding an appeal.

Question 2

advance beneficiary notice of noncoverage (ABN)

Accepted Answer

Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.

Question 3

carrier

Accepted Answer

Health plan; also known as insurance company, payer, or third-party payer.

Question 4

Clinical Laboratory Improvement Amendments (CLIA)

Accepted Answer

Federal law establishing standards for laboratory testing performed in hospital-based facilities, physicians’ office laboratories, and other locations; administered by CMS.

Question 5

Common Working File (CWF)

Accepted Answer

Medicare’s master patient/procedural database.

Question 6

cost sharing

Accepted Answer

The insured’s deductible and coinsurance.

Question 7

fiscal intermediary

Accepted Answer

Government contractor that processes claims for government programs; for Medicare, the fiscal intermediary (FI) processes Part A claims.

Question 8

Health Professional Shortage Area (HPSA)

Accepted Answer

Medicare-defined geographic area offering participation bonuses to physicians.

Question 9

incident-to services

Accepted Answer

Term for services of allied health professionals, such as nurses, technicians, and therapists, provided under the physician’s direct supervision that may be billed under Medicare.

Question 10

Internet-Only Manuals

Accepted Answer

The Medicare online manuals that offer day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives.

Question 11

limiting charge

Accepted Answer

In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service.

Question 12

local coverage determinations (LCDs)

Accepted Answer

Decisions by MACs about the coding and medical necessity of a specific Medicare service.

Question 13

Medical Review (MR) Program

Accepted Answer

A payer’s procedures for ensuring that providers give patients the most appropriate care in the most cost-effective manner.

Question 14

Medical Savings Account (MSA)

Accepted Answer

The Medicare health savings account program.

Question 15

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Accepted Answer

Legislation that redesigned the Medicare Part B reimbursement incentive and mandated the transition to the MBI.

Question 16

Medicare administrative contractor (MAC)

Accepted Answer

New entities assigned by CMS to replace the Part A fiscal intermediaries and the Part B carriers; also known as A/B MACs, they handle claims and related functions for both Parts A and B within specified multistate jurisdictions. DME MACs handle claims for durable medical equipment billed by physicians.

Question 17

Medicare Advantage (MA)

Accepted Answer

Medicare plans other than the Original Medicare Plan.

Question 18

Medicare Beneficiary Identifier (MBI)

Accepted Answer

Medicare beneficiary’s identification number.

Question 19

Medicare card

Accepted Answer

Insurance identification card issued to Medicare beneficiaries.

Question 20

Medicare Integrity Program (MIP)

Accepted Answer

The CMS program designed to identify and address fraud, waste, and abuse, which are all causes of improper payments.

Question 21

Medicare Learning Network (MLN) Matters

Accepted Answer

An online collection of articles that explain all Medicare topics.

Question 22

Medicare Modernization Act (MMA)

Accepted Answer

Short name for the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which included a prescription drug benefit.

Question 23

Medicare Part A (Hospital Insurance [HI])

Accepted Answer

The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home healthcare, and hospice care.

Question 24

Medicare Part B (Supplementary Medical Insurance [SMI])

Accepted Answer

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Question 25

Medicare Part C

Accepted Answer

Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program.

Question 26

Medicare Part D

Accepted Answer

Prescription drug reimbursement plans offered to Medicare beneficiaries.

Question 27

Medicare Summary Notice (MSN)

Accepted Answer

Type of remittance advice from Medicare to beneficiaries to explain how benefits were determined.

Question 28

Medigap

Accepted Answer

Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage.

Question 29

national coverage determination (NCD)

Accepted Answer

Medicare policy stating whether and under what circumstances a service is covered by the Medicare program.

Question 30

notifier

Accepted Answer

The provider who completes the header on an ABN.

Question 31

Original Medicare Plan

Accepted Answer

The Medicare fee-for-service plan.

Question 32

Quality Payment Program (QPP)

Accepted Answer

Two-track value-based reimbursement system designed to incentivize high quality of care over service volume.

Question 33

recovery auditor program

Accepted Answer

A Medicare postpayment claim review program.

Question 34

roster billing

Accepted Answer

Under Medicare, simplified billing for pneumococcal, influenza virus, and hepatitis B vaccines.

Question 35

screening services

Accepted Answer

Tests or procedures performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease; used to detect an undiagnosed disease so that medical treatment can begin.

Question 36

telehealth/E-visit

Accepted Answer

A category of E/M codes covering non-face-to-face office visits such as those via telephone or secure platforms like electronic health records or secure email.

Question 37

United States Preventive Services Task Force (USPSTF)

Accepted Answer

An independent panel of nonfederal experts in prevention and evidence-based medicine that conducts scientific evidence review of a broad range of clinical preventive healthcare services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems.

Question 38

urgently needed care

Accepted Answer

In Medicare, a beneficiary’s unexpected illness or injury requiring immediate treatment; Medicare plans pay for this service even if it is provided outside the plan’s service area.

Question 39

waived tests

Accepted Answer

Particular low-risk laboratory tests that Medicare permits physicians to perform in their offices.

Question 40

“Welcome to Medicare” preventive visit

Accepted Answer

This initial review of Medicare Part B provides a baseline examination of a beneficiary’s medical and social history.

Question 41

Yearly “Wellness” Visit

Accepted Answer

preventive service providing a health risk assessment and personal prevention plan.

MED112 CODE/BILL

MED112 KEY TERMS CH 09

Term	Definition
MED112 CH 8 KEY TERMS
additional documentation request (ADR)	A communication from a Medicare Program Review contractor that asks for more information regarding an appeal.
advance beneficiary notice of noncoverage (ABN)	Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.
carrier	Health plan; also known as insurance company, payer, or third-party payer.
Clinical Laboratory Improvement Amendments (CLIA)	Federal law establishing standards for laboratory testing performed in hospital-based facilities, physicians’ office laboratories, and other locations; administered by CMS.
Common Working File (CWF)	Medicare’s master patient/procedural database.
cost sharing	The insured’s deductible and coinsurance.
fiscal intermediary	Government contractor that processes claims for government programs; for Medicare, the fiscal intermediary (FI) processes Part A claims.
Health Professional Shortage Area (HPSA)	Medicare-defined geographic area offering participation bonuses to physicians.
incident-to services	Term for services of allied health professionals, such as nurses, technicians, and therapists, provided under the physician’s direct supervision that may be billed under Medicare.
Internet-Only Manuals	The Medicare online manuals that offer day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives.
limiting charge	In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service.
local coverage determinations (LCDs)	Decisions by MACs about the coding and medical necessity of a specific Medicare service.
Medical Review (MR) Program	A payer’s procedures for ensuring that providers give patients the most appropriate care in the most cost-effective manner.
Medical Savings Account (MSA)	The Medicare health savings account program.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)	Legislation that redesigned the Medicare Part B reimbursement incentive and mandated the transition to the MBI.
Medicare administrative contractor (MAC)	New entities assigned by CMS to replace the Part A fiscal intermediaries and the Part B carriers; also known as A/B MACs, they handle claims and related functions for both Parts A and B within specified multistate jurisdictions. DME MACs handle claims for durable medical equipment billed by physicians.
Medicare Advantage (MA)	Medicare plans other than the Original Medicare Plan.
Medicare Beneficiary Identifier (MBI)	Medicare beneficiary’s identification number.
Medicare card	Insurance identification card issued to Medicare beneficiaries.
Medicare Integrity Program (MIP)	The CMS program designed to identify and address fraud, waste, and abuse, which are all causes of improper payments.
Medicare Learning Network (MLN) Matters	An online collection of articles that explain all Medicare topics.
Medicare Modernization Act (MMA)	Short name for the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which included a prescription drug benefit.
Medicare Part A (Hospital Insurance [HI])	The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home healthcare, and hospice care.
Medicare Part B (Supplementary Medical Insurance [SMI])	The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
Medicare Part C	Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program.
Medicare Part D	Prescription drug reimbursement plans offered to Medicare beneficiaries.
Medicare Summary Notice (MSN)	Type of remittance advice from Medicare to beneficiaries to explain how benefits were determined.
Medigap	Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage.
national coverage determination (NCD)	Medicare policy stating whether and under what circumstances a service is covered by the Medicare program.
notifier	The provider who completes the header on an ABN.
Original Medicare Plan	The Medicare fee-for-service plan.
Quality Payment Program (QPP)	Two-track value-based reimbursement system designed to incentivize high quality of care over service volume.
recovery auditor program	A Medicare postpayment claim review program.
roster billing	Under Medicare, simplified billing for pneumococcal, influenza virus, and hepatitis B vaccines.
screening services	Tests or procedures performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease; used to detect an undiagnosed disease so that medical treatment can begin.
telehealth/E-visit	A category of E/M codes covering non-face-to-face office visits such as those via telephone or secure platforms like electronic health records or secure email.
United States Preventive Services Task Force (USPSTF)	An independent panel of nonfederal experts in prevention and evidence-based medicine that conducts scientific evidence review of a broad range of clinical preventive healthcare services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems.
urgently needed care	In Medicare, a beneficiary’s unexpected illness or injury requiring immediate treatment; Medicare plans pay for this service even if it is provided outside the plan’s service area.
waived tests	Particular low-risk laboratory tests that Medicare permits physicians to perform in their offices.
“Welcome to Medicare” preventive visit	This initial review of Medicare Part B provides a baseline examination of a beneficiary’s medical and social history.
Yearly “Wellness” Visit	preventive service providing a health risk assessment and personal prevention plan.

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