Government
These are the components that the total RVU is comprised of for physician services.
What is physician work, practice expense (PE), and malpractice insurance (MP)?
Total RVU is based on three components of physician services: physician work, practice expense (PE) and malpractice insurance (MP).
Medicaid agencies are required to report EPSDT performance information this many times a year.
What is Annually?
State Medicaid agencies must inform all Medicaid-eligible individuals under the age of 21 that EPSDT services are available, provide or arrange for the provision of screening services for all children, arrange for corrective treatment as determined by the health screenings, and report the performance information on an annual basis.
The acronym "MAC" stands for this.
What is Medicare Administrative Contractor?
Medicare Administrative Contractor (MAC) administers, and processes claims for Medicare Part A and Part B services organized in multi-state regions.
TRICARE is the healthcare program for this department of the US government.
What is the Department of Defense?
TRICARE, formerly known as CHAMPUS, is the Department of Defense healthcare program for military families and retirees.
The timely filing for TRICARE and CHAMPVA.
What is 1 year from the date of service?
Rationale: TRICARE and CHAMPVA both have a one-year timely filing limit. There are exceptions allowed for retroactive benefit issues when the time frame for filing goes back to your eligibility date. In those cases, once notified, 180 days are allowed to submit a claim.
Medicare’s payment amount for services is determined by this formula.
What is Total RVU X Conversion factor(CF) = Medicare payment?
Medicare payments are determined based on the Total RVU X Conversion Factor. The complete formula includes [(Work RVU X Work GPCI) + (RVUPE X PE GPCI) + (MP RVU X MP GPCI)] = Total RVU X Conversion Factor = Medicare payment
The term used for a supplemental policy for Medicare.
What is Medigap?
Rationale: Medigap is a Medicare supplemental policy to help cover costs that are not covered by Medicare.
The acronym EPSDT stands for.
What is Early and Periodic Screening, Diagnostic, and Treatment?
Barbara’s late husband, Joe, was a lieutenant in the Navy. He served for 30 years, retiring 10 years prior to his death. Barbara will still have healthcare coverage as Joe’s widow under which of the following healthcare programs.
What is CHAMPVA?
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is the healthcare program in which the Department of Veterans Affairs covers spouses, widows and widowers, and the children of a veteran who is rated permanently and totally disabled due to a service connected disability, died of a service-connected disability, or died on active service and the dependents are not eligible for TRICARE.
CMS updates their conversion factor this many times a year.
What is Annually?
The conversion factor is updated annually.
These resources will indicate if a service or procedure is payable, noncovered, or bundled into another service.
What are status codes?
Status codes should be reviewed to determine the status of a code, i.e. A= Active code, B=Bundled code, D=Deleted, etc.
These mandatory benefits must be provided by Medicaid programs to receive matching federal funding.
What are: Outpatient hospital services, home health services, Federally Qualified Health Centers services and inpatient hospital services?
Outpatient hospital services, home health services, Federally Qualified Health Centers services, and inpatient hospital services are among some of the mandatory services required to secure matching federal funding. A complete listing of mandatory and optional benefits can be accessed at the following website.
Source: https://www.medicaid.gov/chip/state-program-information/index.html
Medicaid’s minimum eligibility is based on this.
What is Federal poverty level?
Medicaid eligibility must meet a variety of conditions and allow for variances from state to state, however, the minimum eligibility factor that all Medicaid programs have in common is the federal poverty level (FPL) which is a pre-determined annual income amount for a family of four.
Andrew has selected TRICARE Prime as his health plan. This person will be responsible for coordinating his health care, maintaining his medical records, and referrals to specialists when needed.
What is PCM- Primary Care Manager?
TRICARE Prime is a managed care model in which the insured will be assigned a primary care manager who will be responsible for coordination of care, medical record maintenance, and referrals.
A 45-year-old patient is diagnosed with N18.6. Based on this diagnosis, this patient will be eligible for Medicare coverage because he has this condition.
What is ESRD?
Medicare is a health insurance program for people age 65 and older, people under 65 with certain disabilities, and people of any age with end stage renal disease.
This service is NOT considered preventive by Medicare.
What are dentures?
Screenings for a variety of medical conditions, as well as annual wellness visits, vaccinations for influenza, pneumonia, and Hepatitis B are deemed preventive. A comprehensive listing of preventive services can be accessed on the CMS website. Dentures and most dental care are not covered.
This is who sells Medicare Supplement Insurance policies or Medigap.
Who are private insurance companies?
Medigap refers to a Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover.
The Clinical Prior Authorization (PA) Program assists in monitoring these.
What are Drug classes?
Clinical Prior Authorization (PA) Program was implemented to manage drug classes that require additional monitoring, ensuring drugs are being prescribed for the right patients and the appropriate reasons, as well as monitoring drug expenditures.
This TRICARE option allows enrollees the most choices by utilizing the fee-for-service model.
What is TRICARE Select?
TRICARE Select is a fee-for-service option that allows the enrollees the most choices.
A patient receiving inpatient care in a critical access hospital would be covered under this part of Medicare.
What is Part A?
Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities for Medicare patients.
This is a Medicare statutorily excluded service.
What are non-covered items and services?
Noncovered items and services are statutorily excluded and are not reimbursed by Medicare. Examples of statutorily excluded services are routine foot care, cosmetic surgery, and acupuncture.
When processing Medigap claims, Item 9a of the CMS-1500 claim form must have the policy and/or group number of the Medigap insured preceded by this.
What is "MG"?
MEDIGAP, MG, or MGAP must precede the policy or group number in Item 9a of the CMS-1500 claim form to allow for proper processing of Medigap claims.
Medicaid claims must be filed in this time frame.
What is 95 days?
Medicaid timely filing requirements will vary from state to state. Billers need to be aware of the filing limits within the individual state
This TRICARE option is available for active-duty service members to join.
What is Tricare Prime?
Rationale: All active-duty service members must choose TRICARE Prime. TRICARE Reserve Select and Select options are not available for active-duty members.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a program associated with this insurance carrier.
What is Medicaid?
EPSDT is a benefit of Medicaid that provides comprehensive and preventive healthcare services for enrolled children under the age of 21