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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

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