Miscellaneous
This form is used to submit charges for outpatient services to health insurance companies
What is CMS 1500
A written recommendation from a specialist to a specialist
What is tertiary referral
A written notice that a patient receives before receiving medical care that may not be covered
What is ABN (Advance Beneficiary Notice)
How many MCO'S does Medicaid have
What is four
Requirement to qualify for Medicaid
What is low income
Assigning a code that deliberately results in higher payment
What is upcoding
This written statement from an insurance company that summarizes the costs of a medical service or treatment
What is an Explanation of Benefits (EOB)
Which insurance claim form is submitted to receive reimbursement under Medicare Part A
What is UB 04 or CMS 1450
This contains important information about the patient's insurance details needed to verify eligibility
What is an insurance card
How is Medicaid funded
What is federal and state government
Law states that physicians are not allowed to refer patients to a facility with whom they have a financial relationship
What is Stark Law
Which codes are entered in block 21 of the CMS 1500 claim form and provide medical necessity
What is ICD-10-CM codes
Which program includes managed care & private fee-for-service plans that provide contracted care to Medicare patients
What is Medicare Part C or Medicare Advantage
The Medicaid MCO's for Nevada
What is Anthem Medicaid, Silver Summit, HPN, Molina
What does CMS stand for
What is Centers for Medicare and Medicaid Services
Charging write-off or adjustment amounts to beneficiaries is called ____, & is prohibited by Medicare regulations
What is balance billing
Process of requesting approval for a service or procedure by providing medical history to the insurance
What is preauthorization
A program created to assist with amounts left over after Medicare pays
What is Medicare Supplement or Medigap
The private health insurance company that contracts with states to provide Medicaid health care services
What is Managed Care Organization (MCO)
This type of Medicaid program provides health insurance to pregnant women and children in families with incomes up to a certain threshold, often higher than the regular Medicaid eligibility limits.
What is the Children's Health Insurance Program (CHIP)
Reviewing claims for accuracy and completeness
What is auditing
When someone intentionally deceives an insurance company or agent to receive money or benefits they are not entitled to
What is fraud
When a claim is automatically sent to the secondary insurance
What is crossover claim
The audit program that reviews Medicaid claims, and identifies overpayments
What is Medicaid Integrity Contractor (MIC)
Which describes annual income guidelines established by the federal government
What is Federal Poverty Level (FPL)