CRCR study
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| ERA | Electronic Remittance Advice
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| Level 1 of ERA | Receipt of Data/the information is printed
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| Level 2 of ERA | Electronic remittance is received, entered into computer, and viewed at terminal
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| Level 3 of ERA | Electronic remittance is received, entered into computer - remittance data are electronically posted by the patient accounting software, updating the patients account.
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| Level 4 of ERA | Total automation receipt, data entry, payment posting, adjustment processing
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| EFT | is the electronic transfer of funds from payer to payee thru the banking system (fasted way to move money)
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| SNF Services Covered (6) | Room and board, PT, OT, ST, Respiratory Carem Drugs, Blood transfusions, supplies and equipment
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| EDI | Electronic Data interchange
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| EDI used for? | translating, standardizing and sending transactions electronically (claims) 837. 270/271, etc...
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| 835 | Remittance
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| Violation of the DRG Window (3 day) causes | delay in billing, rejection of claim, additionaly sanctions, fines, revocation of medicare status
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| UBO4 is used for institutional providers(List 4) | hospitals, hospice, rural health clinic, snf
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| SNF IP rules | must be IP atleast 3 days before discharging to SNF, must be admitted with in30 days of IP stay.
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| DRG used for | Inpatient billing
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| APC used for | outpatient billing
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| Benefit SNF Period? | 100 Days during a benefit period/ Benefit period ends during which the patient is not a IP or SNF for 60 days.
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| CCI Edits are? | Program consists of Edits implemented w/claim processing to catch errors before sending out
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| Package Pricing is? | payment system in which a lump sum or bundled payment is negotiated between payor and some or all providers.
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| Site of service limitation? | health plans developed care plans for common disease and procedures and must happen in approved setting
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| Title 804 | governs actions of skip tracing
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| Title 805 | Collector communication ceasing communication
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| Title 806 | proibits harassment abuse from the collector
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| Title 807 | deceptive or false representations
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| Title 604 (FCRA) | gives permision to see credit reports by court, by consumer, and a reporting agency who has legitimate business to view
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| Hospice Benefits with Medicare include | 2 90 day periods and unlimited subsequent periods-60 days each
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| CMS 1500 is used by non institutional providers such as | physicians, allied health professions, CRNA, home health agency's and Medical Equipment suppliers
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| What is EFT balancing and Control | Use of EFT greatly simplifies cash balancing and control requirements. The bank notifies the provider of amount received and issues deposit. The provider balances this to the ERA received.
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| Common Provision found in manage care contracts for protection for medical expense that exceed certain levels. | STOP LOSS Protection
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| Per Diem payment | fixed daily payments that do not vary based on level of services/IP
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| Percentage Discount is | where the provider accepts a percentage discount from total charges.
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| Most common contracted payment models (7) | Percentage discount, DRG, APC, Case Rate, Per Diem, Package Pricing, Capitation
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| Method of payment to healthcare providers whereby a FIXED amount is paid per ENROLLEE to cover defined set of services over a specifica period of time | Capitation
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| The difference between providers charges and the insuracne payment that are written off the patients account as... | Contractual allowance
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| The first critical step for all patients arriving for service scheduled or unscheduled is verifying patients identity with 2 forms...list | ID, name, DOB, SSN
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| Time of Service Denials include | new technology used without determining coverage(3D), charges bundled/unbundled incorrectly, accuity level changes but pt type does not change, admission notification not done, Pt IP but should be OBs, test performed not ordered, invalid HPCPS coding
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| Post Service Denials include | late charges, 2 claims with DOS that overlap, untimely filing
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| Pre Service Denials include | No Pre Auth, clinicals not called for certification, INS not verified, Inaccurate Data entry, Copying registration without verifying
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| CLIA | Clinical Laboratory Improvemen Act
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| APC only covered under medicare part | B
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| Impacts of Denials besides loss of reimbursement and additional cost | Productivity(staff reworks files), patient loss of confidence, employee frustration increased(morals affected)
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| Onsite self pay is enhanced by the ability to accept these forms of payment | Cash, Credit, check or debit cards
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| Liability payers include | Auto, Work Comp, Premises for medical coverage under property cases
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| Healthplan process claim from reimbursement and subsequently pursues payment from liability payer is... | SUBORGATION
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| Medicare allows providers to submit liability claims after this waiting period | 120 days.
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| Claim against personal property that secures payment of a debt | Lien
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| CWF | Common Working File
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| Medicare has 2 types of appeals to charges | Beneficiary appeal and Provdier appeal
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| Second Placement accounts are | an agency accepting assignment of returned or cancelled debts from initial collection agency.
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| Title VI is called | Fair Credit Reporting Act
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| The truth and lending act is | Title I- established rules for consumers credit and sales and loans
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| Medicare will try to collect self pay portions for how many days? | 120 days then goes to collections agency
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| For an acount to be considered bad debt collection must have been attempted and documented T/F | True
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| Payment floors for IP claims | 13 days electronic/26 for paper claims
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| MR | Medical Record
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| MPI | Master Patient Index
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| CPI | Corporate Patient Index
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| Critical patient information collected when scheduling are used as identifiers(list 4) | Legal name, DOB, sex, SSN
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| DME examples | Wheelchairs, hospital beds, oxygen tanks
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| Homebound patients requiring periodic skilled nursing and therapeutic care ordered by physician | Home Health Care
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| Patients with incurable disease and have a life expectency of six months or less | Hospice Care
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| Orthopedic surgical patient that require intense PT/stroke PT who require comprehensive Rehab | Skilled Nursing Patients
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| Can you use a ABN for a IP stay | NO
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| When is a ABN required | when a test or service does not meet medical necessity according to LCD/NCD
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| Credit balances are created by | posting errors, billing errors, payment errors, hospital and payer system limitations
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| Chargemaster issues can result in | inappropriate reimbursement
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| Claim rejection is a claim rejected for a # of reasons (list some) | inability to identify patient, ineligibility of pt, noncompliance of the provider with billing requirements.
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| Medicare Claims must be filed within what qualifying time limit? | 1 year
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| Types of unscheduled patients (6) | Emergency, urgent inpatients, routine walkins outpatients, ED outpatients, obs patients, Newborn
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| 3 types of schedule patients | Scheduled IP, Scheduled OP, reaccuring/series
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| Enrollment and disenrollment of a healthplan transanction set | 834
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| What must appear on the ABN? (5 items) | Service physician ordered, cost, date of service, non coverage reason, financial responsibility
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| Capitation Contract Payment Method is | provider received a flat fee every month for taking care of individual
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| Case Rate Contract Patyment Method is | specific condition forms the basis for establishing a single payment for all services(colonscopy)
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| Financial counseling payment options | Full payment proir to service, short term payment plan, bank loan
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| Underpayment denial | payer does not pay the agreed contract(Aetna) amount to provider(LUH)
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| Technical Denial | Demographic error, imcomplete insurance 411, no precert or auth, no contunied stay auth, exceeds frequency limit(pt visits)
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| Clinical Denial | not medically necessary, diagnosis and cpt do not match, carve out days, inappropriate level of care, HCPCS incorrect for procedure
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| Bankruptcy Chapter 7 | Straight- involuntary or voluntary
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| Chapter 11 | debtor reogranization (court supervised plan) within 120 days
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| Chapter 13 | Rehabilitation- does not liquidate-looks for future earnings
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| By siging a contractual agreement(aetna, cigna etc) the facility becomes | In network
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| Rural Hospitals with fewer than BLANK beds can be reimbursed by Medicare | 100 (often use of swing beds)
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| Patient discharged status code | 03
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| 837 transaction set | coordination of benefits
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| 835 transaction set | claim payment/remittance advice
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| 277/278 transaction set | referral certification and authorization
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| 820 transaction set | healthplan premium payments
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