Dollar Dollar bills
What does Medicare Part B do?
80% of doctor's visits after the small deductible is met, Monthly premiums same for everyone, Does not cover prescriptions
Covers preventative medicine at 100% (vaccines & screenings), ICD-10, Covers nebulizers, nebulizer solutions, insulin for pumps, diabetic test strips, durable medical equipment (DME)
What does Medicare Part D do?
Prescription drug insurance, Contracts with private insurers to administer the program, Copays, formularies, and premiums vary
Prescription drug insurance, Contracts with private insurers to administer the program, Copays, formularies, and premiums vary
Tiered Copayment consists of what 2 systems?
Dual Copay
3 to 4 Tiered Copay
The monthly Premium is?
A fee for insurance coverage
The first party responsible for?
covering a medical bill is typically the person who directly receives the benefits.
Define Medicare.
Covers people 65+ years old and disabled people, with chronic kidney disease; administered by the federal government Medicare Parts A, B, C, and D pay for different types of claims.
What does Medicare Part C do?
Comprehensive, The patient does not need 3 separate plans, Administered by private HMOs, PPOs, and fee-for-service plans, and Also called Medicare Advantage
Define Tricare
Covers active military, veterans, and their dependents, administered by the federal government
Coinsurance is?
A specific %’s that insured must pay immediately when receiving a service or drug.
HCPCS is used for?
used to record supplies, equipment, and devices supplied for medical purposes.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is the act of what?
mandates that an employer must retain its former employees in its coverage plans to allow the transition to their following jobs without loss of health insurance.
Preferred provider organizations (PPOs) you to use?
Doctors that have contracts with the plan.
Health maintenance organizations (HMOs) require members to get?
services and products only through their staff or contracted providers and facilities. Will require a referral from their primary physician.
Define the Pharmacy Benefit Manager (PBM).
companies that manage prescription drug benefits on behalf of health insurers.
What does the Prior Authorization do?
Gets More info from the insurance on the prescriber
What is needed from an insurance card?
Bin #
ID #
patient code
DOB
PCN
What does Medicare Part A do?
Covers 80% of hospital stays
Limited coverage of nursing homes or rehabilitation facilities
Premium same for everyone over 65 regardless of income/assets
What are the 3 types of billing codes?
ICD-10
HCPCS
CPT
Copayment is what?
the amount you pay for a healthcare service
What is online adjudication?
refers to billing third parties for goods and services rendered. claim submission is the process of sending a claim to a third party for reimbursement and is also used with a copay.
what is (CHIP), its name, and its definition?
Children’s Health Insurance Programs, cover children, administered by states
What does ICD stand for?
International Classification of Diseases
Define Medicaid
Covers low-income people and their dependents, administered by individual state programs
What is a Deductible?
The amount you must pay before insurance pays.
What does the Drug Utilization Review(DUR) do?
Drug utilization review programs help to ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences.