When a patient has Medicaid coverage in addition to other, third-party coverage, Medicaid is always considered the
payer of last resort
Medicare Part B will cover some home health care services if the patient
does not have Medicare Part A
Which information must be obtained about the beneficiary to confirm Medicare eligibility over the phone?
date of birth
What length of time is the Medicare initial enrollment period (IEP)
7 months
What is the name of the monthly explanation of benefits statement that Medicare patient's receive?
medicare summary notice
Medicare Part A coverage is available to individuals under the age of 65 who
have end-stage renal disease and meet requirements
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
The temporary assistance to needy families (TANF) program provides
cash assistance on a limited time basis for children deprived of support
The Medicare "spell of illness" is also known as the
benefit period
Which is considered a mandatory Medicaid service that states must offer to receive federal matching funds?
preauthorized services
All terminally ill Medicare patients qualify for _________ care
hospice
Which is a characteristic of Medicare enrollment?
eligible individuals are automatically enrolled, or they apply for coverage
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 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
Tricare Standard and Extra were combined to create Tricare
Select
In which Tricare option are active military personnel required to enroll?
Tricare Prime
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
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
Medicaid is jointly funded by federal and state governments, and each state
administers its own Medicaid program
The term sponsor is used to describe
active duty, retired, or deceased military personnel
Which Tricare option is a fee-for-service plan?
Tricare Select
A military treatment facility (MTF) catchment area is
defined by code boundaries with 40-mile radius of an MTF
Which requirements are used to determine Medicaid eligibility for mandatory categorically needy eligibility groups?
TANF
How often should providers verify a patient's Medicaid eligibility
at each encounter
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
The entity responsible for the prevention, detection, investigation, and control of Tricare fraud, waste, and abuse is the
Program integrity office
The maximum that Medicare will reimburse a nonPAR for a covered service is 80 percent of the
limiting charge
Early and Periodic Screening, Diagnostic,and Treatment (EPSDT) services are offered for which Medicaid-enrolled population?
individuals under age 21
The entire health care system of the U.S. uniformed services is known as the
Military Health System (MHS)
Patients may elect to use their Medicare lifetime reserve days after how many continuous days of hospitalization?
90
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)
What is included in a couple's combined resources, according to the spousal impoverishment protection legislation?
summer home
State legislatures may change Medicaid eligibility requirements
during the year, sometimes more than once
Which processes traditional Medicare claims?
medicare administrative contractor
The health care program for active duty members of the military and their qualified dependents is called
Tricare
The Medicaid program is
federally mandated and state administered
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
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
If a patient has retiree group health plan coverage (including from his spouse's former employment), the group health plan pays
first
The organization responsible for coordinating and administering the Tricare program is the
Tricare Management Activity
Commanders of selected military treatment facilities for Tricare regions are called
lead agents
A critical pathway is the
sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment
A Medicaid card issued for the "unborn child of......" is good for
services that promote the life and health of the unborn child
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
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
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
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
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
One of the benefits of becoming a Medicare participating provider (PAR) is
faster processing and payment of assigned claims
The number of Tricare regions has __________since originally established
decreased
A Medicare nonparticipating provider is not allowed to
utilize balance billing
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
Which is subject to Medicaid preauthorization guidelines?
any extension of inpatient acute care hospital days
Tricare plans are primary to
Medicaid
Claims are submitted to the Tricare
regional contractors
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
Medicaid reimbursement is expedited when the provider
enters an X in the Yes box in Block 27 to accept assignment
A Medicaid voided claim
should not have been paid originally
Tricare nonparticipating providers are subject to a timing charge of _______ above the Tricare fee schedule for participating providers
15 percent
The managed care option that is similar to a civilian HMO is called Tricare
Prime
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
Which practitioner who submits claims for services must accept assignment?
physician assistant
Supplemental health care programs (SHCPs) are available through military associations and
private third-party payers
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 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
Tricare outpatient claims will be denied if they are filed more than
one year after the date of service
Which services are exempt from Medicaid copayment?
family planning services
The Original Medicare Plan is also called Medicare
fee-for-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
Individuals who are eligible for both Medicare and Medicaid coverage are called
dual eligibles
To receive matching funds through medicaid, states must offer what coverage?
inpatient hospital services
The conversion of CHAMPUS to TRICARE was the result of a(n)
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
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
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
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)
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
Lead agents of selected military treatment facilities (MTFs) hold what rank?
commander
Tricare nurse advisors are available 24/7 to assist with
treatment alternatives and recommendations for care
Medigap coverage is offered to Medicare beneficiaries by
commercial payers
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