What is TANF.....Temporary Assistance for Needy Families (TANF):
100
Ambulatory surgery centers are freestanding facilities with or without affiliation with a particular hospital.
Ambulatory surgery units are departments within a hospital that provide outpatient services.
What is OUTPATIENT CARE
100
ALL UNIFORMED SERVICES SPONSORS AND FAMILY MEMBERS MUST BE ENROLLED IN
What is (DEERS) DEFENSE ENROLLMENT ELIGIBILITY REPORTING SYSTEM
100
Centers for Medicare and Medicaid Services (CMS)
Purpose: To serve as a consolidated agency for Medicare and Medicaid
CMS and Social Security Administration (SSA)
What is MEDICARE ADMINISTRATION
100
Paper claims EOB
Electronic claim ERA
Claim status stated, paid, pending, rejected, or denied
Varied language due to lack of universal form
Reason codes and remark codes found on face or back
What is Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA)
200
SSI recipients
Persons living in medical institutions with monthly income
up to 300% of SSI standard
What is Categorically Needy
200
Hospital confinement is greater than 24 hours.
Hospice facilities provide care for terminally ill patients.
Skilled nursing facilities provide care for patients following hospital stay.
What is INPATIENT CARE
200
AFTER ENROLLMENT INTO TRICARE _________ PLAN EACH INDIVIDUAL IS ASSIGNED ONE OF THESE________
What is PRIME
WHAT IS A (PCM) PRIMARY CARE MANAGER
200
65 or older
Adult with disability
Disabled before age of 18
Entitled individuals’ spouses
End-stage renal disease (ESRD)
What is Medicare Part A Eligibility
200
Charge-based fees charged by many providers for similar services
Resource-based fees charged based on work and overhead risk
Relative value scale (RBRVS)
What is Provider Fees
300
Provides more federal funds to expand Medicaid eligibility
to include more uninsured children
What is (SCHIP): State Children’s Health insurance Program
300
Shows all charges and items provided.
It assists with high volume of billing for services received by hospital patients.
Services and procedures are keyed into computer.
It includes the procedure code, code and service description, charge, and revenue
What is CHARGE DESCRIPTION MASTER
300
Sponsor: Member of military
Beneficiary: Family members of member of military
Service/military retiree: Retired military service member
Uniformed sponsors and family members must register with DEERS.
What is TRICARE ELIGIBILITY
300
Inpatient hospital care: 90 days in a benefit period with 60-day lifetime reserve
Skilled nursing facility: 100 days during a benefit period
Home health care: Part time or intermittent skilled nursing care, home health aide, and therapies along with DME
What is Medicare Part A Coverage
300
PMPM: Per member per month
Capitation rate (cap rate)
Withhold: Money held out to pay or offset additional costs
What is Capitation Plan
400
Mobilizes other services: Preventative, rehabilitative, curative, and supportive care
Care is provided in day health centers, hospitals, and nursing homes.
What is PACE (Programs of All-inclusive Care for the Elderly)
400
Assigned at admission and unique to that confinement
What is Patient control number (PCN):
400
For active duty members not assigned close to an MTF
Available to family members
Same as TRICARE Prime
What is TRICARE Prime Remote
400
Meet requirements for Part A
Purchase Part A
Part B purchase: Based on annual income
Meet deductible: Yearly
What is Medicare Part B Eligibility
400
Amount paid by patient before benefits begin
What is Deductible
500
Always verify patient status prior to seeing the physician
Some electronic verification available
Check for restricted status, which requires the patient to see a specific physician (e.g., PCP) and/or pharmacy
What is Medicaid Verification
500
Form of prospective pay using categories of similar patients
Patient classification past and current
Variables responsible for DRG classification
What is (DRG'S) DIAGNOSIS RELATED GROUPS
500
Alternative managed care plan for individuals not having priority at an MTF
Active duty not eligible
More expensive than Prime, less expensive than Standard
Annual deductible
What is TRICARE EXTRA
500
Established in 1997: Same benefits as part A and B
Now Medicare Advantage Plus
Additional benefits: Hearing aids, dentures, and prescription drugs
Types of plans
What is Medicare Part C (Medicare + Choice)
500
1. Percentage of calculated charge paid by the patient
2. Amount paid by patient at time of service