Medical Billing and Coding | Baamboozle - Baamboozle

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)is a comprehensive health care program for which the _______ shares costs of covered health care services and supplies with eligible beneficiaries

Department of veterans affairs

Supplemental health care programs (SHCPs) are available through military associations and

private third-party payers

Tricare has established a good-faith policy for assigned claims to protect the provider when

a patient presented an ID card and it turned out to be invalid

Tricare outpatient claims will be denied if they are filed more than

one year after the date of service

Which Tricare option has costs that vary based on sponsor's military status, and includes an annual outpatient deductible and cost shares (or percentages) for covered services?

Tricare Select

If a Tricare Prime beneficiary seeks care from a facility outside of the treatment area without prior approval, the point-of-service option is activated. This will result in what cost(s) to the beneficiary?

an annual deductible plus 50 percent or more of visit or treatment fees

A military treatment facility (MTF) catchment area is

defined by code boundaries with 40-mile radius of an MTF

In which Tricare option are active military personnel required to enroll?

Tricare Prime

Which Tricare option is a fee-for-service plan?

Tricare Select

The entity responsible for the prevention, detection, investigation, and control of Tricare fraud, waste, and abuse is the

Program integrity office

Tricare nurse advisors are available 24/7 to assist with

treatment alternatives and recommendations for care

Tricare plans are primary to

Medicaid

Claims are submitted to the Tricare

regional contractors

The term sponsor is used to describe

active duty, retired, or deceased military personnel

The organization responsible for coordinating and administering the Tricare program is the

Tricare Management Activity

The entire health care system of the U.S. uniformed services is known as the

Military Health System (MHS)

Lead agents of selected military treatment facilities (MTFs) hold what rank?

commander

The number of Tricare regions has __________since originally established

decreased

Which is a comprehensive health care program for which the Department of Veterans Affairs shares costs of covered health care services and supplies with eligible beneficiaries?

CHAMPVA

Tricare nonparticipating providers are subject to a timing charge of _______ above the Tricare fee schedule for participating providers

15 percent

Tricare Standard and Extra were combined to create Tricare

Select

The managed care option that is similar to a civilian HMO is called Tricare

Prime

A critical pathway is the

sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment

Who assists Tricare sponsors with information about the health program, along with other matters affecting access to health care (e,g., appointment scheduling)?

customer service representative

Which office coordinates and administers the Tricare program and is accountable for the quality of health care provided to members of the uniformed services and their eligible dependents?

Tricare Management Activity (TMA)

Commanders of selected military treatment facilities for Tricare regions are called

lead agents

The health care program for active duty members of the military and their qualified dependents is called

Tricare

Medicaid policies for eligibility are complex and vary among states; thus, a person who is eligible for Medicaid in one state

may not be eligible in another state

A Medicaid card issued for the "unborn child of......" is good for

services that promote the life and health of the unborn child

Medicaid reimbursement is expedited when the provider

enters an X in the Yes box in Block 27 to accept assignment

One way the federal government verifies receipt of Medicaid services by a patient is by use of

a monthly survey sent to a sample of Medicaid recipients requesting verification

A Medicaid voided claim

should not have been paid originally

A primary care provider in a Medicaid primary care case management (PCCM) plan differs from an HMO primary care provider in the Medicaid primary care provider is

not at risk for the cost of care provided

An individual whose income is at or below 100 percent of the federal poverty level (FPL) and has resources at or below twice the standard allowed under the SSI program may receive assistance from Medicaid to pay for Medicare premiums, deduc

and coinsurance amounts as a qualified Medicare beneficiary (QDWI)

Which services are exempt from Medicaid copayment?

family planning services

Which is subject to Medicaid preauthorization guidelines?

any extension of inpatient acute care hospital days

Programs of All-inclusive Care for the Elderly (PACE) work to limit out-of-pocket costs to beneficiaries by

not applying deductibles, copayments, or other cost-sharing

Early and Periodic Screening, Diagnostic,and Treatment (EPSDT) services are offered for which Medicaid-enrolled population?

individuals under age 21

To receive matching funds through medicaid, states must offer what coverage?

inpatient hospital services

When a patient has become retroactively eligible foe medicaid benefits, any payments made by the patient during the retroactive period must be

refunded to the patient by the practice

What is included in a couple's combined resources, according to the spousal impoverishment protection legislation?

summer home

The temporary assistance to needy families (TANF) program provides

cash assistance on a limited time basis for children deprived of support

The Medicaid program is

federally mandated and state administered

The conversion of CHAMPUS to TRICARE was the result of a(n)

successful CHAMPUS Reform initiative (CRI) demonstration project

Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary which means the services are

consistent with the patient's symptoms, diagnosis, condition, or injury

Which is considered a voided claim?

claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider

When a patient has Medicaid coverage in addition to other, third-party coverage, Medicaid is always considered the

payer of last resort

Individuals who are eligible for both Medicare and Medicaid coverage are called

dual eligibles

Which is considered a mandatory Medicaid service that states must offer to receive federal matching funds?

preauthorized services

How often should providers verify a patient's Medicaid eligibility

at each encounter

States that opt to include a medically needy eligibility group in their Medicaid program are required to include certain children who are under the age of ______ and who are full-time students

21

Which requirements are used to determine Medicaid eligibility for mandatory categorically needy eligibility groups?

TANF

State legislatures may change Medicaid eligibility requirements

during the year, sometimes more than once

Medicaid is jointly funded by federal and state governments, and each state

administers its own Medicaid program

If a service was performed on June 30, the Medicare claim must be submitted for payment and postmarked no later than

June 30 of the next year

Medicare can assign a claim conditional primary payer status for payment processing. Which of the following would warrant this type of conditional status?

a patient who is mentally impaired failed to file a claim with the primary payer

Although they may do so more frequently, how often are providers required to collect or verify Medicare as Secondary Payer (MSP) information?

after a primary Medicare claim has been denied

Which practitioner who submits claims for services must accept assignment?

physician assistant

The maximum that Medicare will reimburse a nonPAR for a covered service is 80 percent of the

limiting charge

One of the benefits of becoming a Medicare participating provider (PAR) is

faster processing and payment of assigned claims

Dr. Cummings has been practicing in town for nearly 30 years. As a courtesy to his loyal Medicare patients, he does not charge the coinsurance. How can this affect Dr. Cummings's practice?

the doctor may be subject to large fines and exclusion from the Medicare program

Which component of the Medicare Modernization Act of 2003 was created to provide tax-favored treatment for individuals covered by a high-deductible health plan?

Medicare savings accounts

Medicare Part B will cover some home health care services if the patient

does not have Medicare Part A

All terminally ill Medicare patients qualify for _________ care

hospice

Temporary hospitalization of a patient for the purpose of providing relief from duty for the nonpaid primary caregiver of a patient is called_______ care

respite

For a beneficiary to qualify for Medicare's skilled nursing benefit, the individual must have

had at least three inpatient days of an acute hospital stay

Patients may elect to use their Medicare lifetime reserve days after how many continuous days of hospitalization?

90

The Medicare "spell of illness" is also known as the

benefit period

What length of time is the Medicare initial enrollment period (IEP)

7 months

Which information must be obtained about the beneficiary to confirm Medicare eligibility over the phone?

date of birth

Medicare Part A coverage is available to individuals under the age of 65 who

have end-stage renal disease and meet requirements

Which is a written document provided to a Medicare beneficiary by a provider prior to rendering a service that is unlikely to be reimbursed by Medicare?

advance beneficiary notice of noncoverage

A Medicare nonparticipating provider is not allowed to

utilize balance billing

Medigap coverage is offered to Medicare beneficiaries by

commercial payers

The Original Medicare Plan is also called Medicare

fee-for-service

Which is the total number of Medicare lifetime reserve days (defined as the number of days that can be used just once during a patient's lifetime)?

60

Which processes traditional Medicare claims?

medicare administrative contractor

Which is a characteristic of Medicare enrollment?

eligible individuals are automatically enrolled, or they apply for coverage

What is the name of the monthly explanation of benefits statement that Medicare patient's receive?

medicare summary notice

If a patient has retiree group health plan coverage (including from his spouse's former employment), the group health plan pays

first