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Chapter 13 Medicaid
Medicaid & other state programs
| Question | Answer |
|---|---|
| AFDC | Aid to Families with dependent children |
| MI | medically indigent |
| TAR | treatment authorization request |
| program of medical assistance for certain low-income individuals and families is known as what? | Medicaid in 49 states |
| in California a program of medical assistance for certain low-income individuals and families is known by another name instead of Medicaid - what is it? | Medi-Cal |
| What is the only state without a Meicaid program similar to those existing in other states? | Arizone |
| Medicaid is administered by who? | by state governments with partial federal funding |
| Coverage and benefits vary widely from state to state because of what two factors? | 1. federal government sets minimum standards 2. states are free to enact more benefits |
| CMS | Centers for Medicaid and Medicare Services |
| What agency is responsible for the federal aspects of Medicaid? | CMA of the Bureau of Program Operations of the U.S. Dept. of Health & Human Services |
| Medicaid is not so much an insurance program as it is what? | an assistance program |
| SCHIP | State Children's Health Insurance Program - insures children from families where income is below 200% of the federal poverty level State Children's Health Insurance Program |
| MCHP | Maternal and Child Health Program |
| Name 3 aid programs for Medicare patients who have low incomes and difficulty paying Medicare premiums, copays & deductibles. | 1. Medicaid Qualified Medicare Beneficiary Program 2. Specified Low-Income Medicare Beneficiary Program 3. Qualifying Individuals Program |
| Name 6 categories of Medicaid eligibility | 1. needy and low-income 2. elderly age 65 and older 3. blind 4. disabled 5. members of families with dependent children deprived of support of at least one parent & eligible on basis of income 6. US citizen or qulified immigrant |
| What are two classifications that contain several basic groups of needy and low-income individuals? | 1. categorically needy-getting cash assistance 2. medically needy |
| EPSDT | Early and Periodic Screening, diagnosis & treatment |
| On a telephone call for prior approval for a service what information should be obtained? | Date & time of that the authorization was given, name of the person who gave the authorization and any verbal number given by the field office. |
| Time limit for submission of a claim can vary within what timeframe? | from 2 months to 12 or 18 months |
| What is the time limit for submission of a claim in CA? | 6 months |
| Medicaid claims are filed on what form? | CMS-1500 |
| When Medicaid and a third-party payer covers a patient, which coverage is considered the payer of last resort? | Medicaid |
| For Medicaid patients who have a liability claim which is billed first? | The liability company; after liability carrier pays then Medicaid is billed with copy of 3rd party EOB attached |
| If a Medicaid patient has Medicare, TRICARE or CHAMPVA always send the claim first to which? | To the federal program fiscal agent - claim will crossover to Medicaid |
| What is the time limit to appeal a claim? | Usually 30 to 60 days from the date listed on the RA. |
| What are the levels of appeal on a Medicaid claim? | 1. regional fiscal agent or Medicaid bureau 2. Dept. of Social Welfare or Human Services 3. Appellate court |
| Medicaid is administered by who? | state government |
| Medicaid is partially funded by whom? | federal government |
| medicaid is what type of program? | an assistance program |
| in all other states, the program is known as Medicaid, but in CA the program is called what? | Medi-Cal |
| because the federal government sets minimum requirements,states are free to enhance the Medicaid program. Name two ways in which Medicaid programs vary from state to state. | Coverage and benefits |
| SCHIP means | State Children's Health Insurance Program |
| MCHP means what and covers who? | Maternal and Child Health Program and covers children younger than age 21 |
| Name 3 aid programs for low-income Meicare patients | 1. Medicaid Qualified Medicare Beneficiary Program 2. Specified Low-Income Medicare Beneficiary Program 3. Qualifying Individuals Program |
| name two broad classifications of people eligible for Medicaid assistance | 1. categorically needy 2. medically needy |
| name the program for the prevention, early detection and treatment of conditions of children receiving welfare is know as what? | Early and Periodic Screening, diagnosis and treatment (EPSDT) |
| insurance claim form for submitting Medicaid claims in all states is what? | CMS-1500 |
| what procedure is followed in billing a patient claim who has Medicaid and TRICARE? | electronically send TRICARE claim first then bill Medicare with a copy of the TRICARE EOB |
| Name five categories of adjudicated claims that may appear on a medicaid remittance advice document: | 1. adjustments 2. approvals 3. denials 4. suspends 5. audit/refund transactions |
| when professional services are rendered the medicaid ID card or electronic verification must show eligibility for what? | month of service |
| when a medicaid patient is injured in an auto accident and the car has liability insurance, this involves a 3rd party payer so the insurance claim is sent to who? | the auto insurance carrier |
| a patients medicaid eligibility may be verified by | 1.touch-tone phone 2. modem 3. special Medicaid terminal equipment |
| when a medicaid patient requires a piece of durable medical equipment, the physician must do what? | obtain prior authorization, preferably written |
| medicare benficiaries who are disabled but have annual incomes below the federal poverty level may be eligible for | Medicaid Qualified Medicare Beneficiary Program Qualifying Individuals Program Specified Low-Income Medicare Beneficiary Program |
| true or false: cerebral palsy is a condition that qualifies a child for benefits under the Maternal and Child Health Program | true |
| true or false: there is only one type of copayment requirement in the Medicaid program | false |
| true or false: when filing a claim for a Medicaid managed care patient, transmit the claim to the managed care organization and not the Medicaid fiscal agent | true |
| true or false: providers must enroll for participation in the Medicaid program with the fiscal agent for their region | true |
| true or false: a stage agency that investigates complaints of mistreatment in a LTCF is the Medicaid Fraud Control Unit | true |
| true or false: in Medicaid a prior approval is not neede in a bone fide emergency | true |
Created by:
mpeoples