CPB Chapter 11 Flashcards

Questions and Answers

There is an annual deductible for active-duty members enrolled in TRICARE Prime.

False

Which of the following is a TRICARE Prime option for active-duty service members?

TRICARE Prime Remote (correct)

TRICARE for Life

CHAMPVA

TRICARE Select

What does TRICARE Select allow enrollees to do?

See any TRICARE-authorized provider without a referral.

What is TRICARE for Life?

Medicare wrap-around coverage for TRICARE eligible beneficiaries with Medicare Part A and B. Signup and view all the answers

What is required for a member to enroll in TRICARE Reserve Select?

They must be a member of the Selected Reserve and not on active-duty orders. Signup and view all the answers

CHAMPVA is ___ insurance.

fee-for-service Signup and view all the answers

Who is eligible for CHAMPVA?

Spouse or child of a veteran rated permanently and totally disabled, or who died from a VA-rated service-connected disability. Signup and view all the answers

What percentage does CHAMPVA pay for covered outpatient services?

75 Signup and view all the answers

What is an original source document in Medicare claims?

Routing slip, superbill, encounter form, charge slip, etc. Signup and view all the answers

Which of the following are common Medicare denials? (Select all that apply)

Patient covered by another payer Signup and view all the answers

What are the five levels of the claims appeal process under Medicare?

Level 1 - Redetermination, Level 2 - Reconsideration, Level 3 - Administrative Law Judge, Level 4 - Appeals Council, Level 5 - Judicial Review. Signup and view all the answers

What must be included in a Level 1 redetermination request?

Beneficiary's name, HIC number or MBI, specific service(s) for redetermination, date(s) of service, name and signature of the party. Signup and view all the answers

How long does a provider have to bill Medicare for services rendered?

12 months Signup and view all the answers

Providers that have opted out of Medicare can bill Medicare for their services.

False Signup and view all the answers

A patient has signed an Advance Beneficiary Notice (ABN) after receiving a service. Can the patient be balance billed?

No. The ABN must be signed before the service is performed. Signup and view all the answers

What is CHIP?

Children's Health Insurance Program. Signup and view all the answers

What does TANF stand for?

Temporary Assistance for Needy Families. Signup and view all the answers

What is EPSDT?

Early, Periodic, Screening, Diagnosis, and Treatment. Signup and view all the answers

What is Medigap?

Medicare supplemental policy sold by private insurance companies. Signup and view all the answers

What are the mandatory benefits that Medicaid must provide?

Mandatory categorically needy, optional categorically needy, and medically needy. Signup and view all the answers

If the provider was a participating provider and is changing to opt-out, they must file the affidavit with carriers that have jurisdiction over claims no later than ___ after the first private contract is entered into.

10 days Signup and view all the answers

What defines incident-to services according to Medicare?

Services furnished incident-to physician professional services in the physician's office or in a patient's home. Signup and view all the answers

To qualify as incident-to services, what must be true about the initial service?

The reporting physician must personally perform the initial service. Signup and view all the answers

What happens to claims when they are performed by Non-Physician Practitioners (NPPs) and do not meet incident-to requirements?

Billed under the NPP's own NPI numbers. Signup and view all the answers

When submitting incident-to claims in a group practice, which physician should the service be billed under?

Physician present providing supervision. Signup and view all the answers

A National Provider Identifier (NPI) is not required for providers that bill Medicare.

False Signup and view all the answers

What information is NOT needed to complete an NPI application?

Provider's favorite color Signup and view all the answers

ABN stands for Advance Beneficiary Notice.

True Signup and view all the answers

What does ABN serve as?

Written notice about potential non-coverage of specific items or services. Signup and view all the answers

Match the following terms with their definitions:

CMS-R-131 = ABN MSP = Medicare as Secondary Payer GA = Waiver of Liability Statement Issued GX = Notice of Liability Issued Signup and view all the answers

Which of the following is a common reason for Medicare noncoverage?

Medicare does not pay for this test for your condition. Signup and view all the answers

How long should an ABN be kept on file?

Five years. Signup and view all the answers

Exceptions that allow a provider to submit claims on paper typically include:

All of the above Signup and view all the answers

What are the eligibility criteria for TRICARE Young Adult?

Both A and C Signup and view all the answers

Non-participating (non-PAR) providers can charge above the Medicare approved amount.

True Signup and view all the answers

What does Medicare cover regarding individuals aged 65 and older?

Individuals aged 65 and older or those under 65 with certain disabilities or ESRD. Signup and view all the answers

What are the four parts of Medicare?

Part A, Part B, Part C, Part D. Signup and view all the answers

Medicare Advantage Plans must be equivalent to regular Part A and Part B.

True Signup and view all the answers

Which information is listed on a Medicare card?

All of the above Signup and view all the answers

What is required for Part A eligibility at 65?

All of the above Signup and view all the answers

To be eligible for Part B at 65, what must you be entitled to?

Premium-free Part A benefits Signup and view all the answers

A patient can be eligible for Medicare Part C and Part D if they are eligible for Part A.

True Signup and view all the answers

The patient's ________ identifier number is unique and consists of 11 characters.

Medicare beneficiary Signup and view all the answers

What is covered under Medicare for cardiovascular disease screening?

Cholesterol and other blood lipid levels. Signup and view all the answers

What type of care does Medicare not cover?

All of the above Signup and view all the answers

Opt-out physicians can charge any amount they desire.

True Signup and view all the answers

What restricts the coverage of services not medically reasonable and necessary under Medicare?

Statutory exclusions and Medicare guidelines. Signup and view all the answers

Study Notes

TRICARE Young Adult

Available for adult children aged 21 to 26 who are unmarried and enrolled in an approved higher education institution.
Coverage options include TRICARE Young Adult Prime and TRICARE Young Adult Select.

Non-participating (Non-PAR) Providers

Fee schedule set at 95% of amounts approved for participating (PAR) providers.
May charge above Medicare approved amounts with a limiting charge capped at 115%.
Required to submit claims to Medicare, with payments received by the patient.
Allowed to accept Medicare assignment on a case-by-case basis, except for clinical lab claims.

Medicare Eligibility

Available to individuals aged 65+, those under 65 with disabilities, and individuals with end-stage renal disease (ESRD).

Medicare Parts Overview

Part A: Covers inpatient hospital care, skilled nursing facilities, hospice, and home health services.
Part B: Covers medical services not included in Part A like physician services, preventive care, and outpatient services.
Part C: Medicare Advantage Plans offering at least equivalent coverage to Part A and B, often with added benefits like vision and dental.
Part D: Prescription drug coverage.

Medicare Advantage Plans

Some plans include Part D coverage.
Managed by private insurers contracted as Medicare Administrative Contractors (MACs).

Medicare Card Details

Includes the patient’s name, effective coverage date, and what Medicare parts are covered.
Unique Medicare Beneficiary Identifier (MBI) format: 11 characters (numbers and letters) with specific positions designated for letters and numbers.

Part A Eligibility at Age 65

Individuals eligible for Social Security benefits or railroad retirement benefits, or having sufficient work history in government jobs where Medicare taxes were paid.

Part A Eligibility Before Age 65

Criteria include entitlement to Social Security disability benefits for 24 months, certain disabilities (including ALS), and qualifying for kidney failure benefits.

Part B Eligibility at Age 65

Residents must be entitled to premium-free Part A benefits to qualify for Part B.

Part C and Part D Eligibility

Eligibility for Medicare Part C and D requires eligibility for Medicare Part A.

Medicare Coverage Determinations

Based on federal laws and national/local coverage policies.

Hospice Coverage

Always covered under Medicare Part A.

Alcohol Misuse Screening

Covered annually under Part B for non-dependent Medicare patients, with four counseling sessions possibly covered if misuse is identified.

Annual Wellness Visit (AWV)

Covered once every 12 months after the first 12 months of Part B coverage, with specific CPT codes for billing.

Advance Care Planning

Offered on the same day as AWV, with deductibles waived when associated with an AWV.

Bone Mass Measurements

Covered under Part B based on specific risk factors and provider recommendations, limited to once every 24 months unless medically necessary sooner.

Cardiovascular Disease Screening

Covered every five years under Part B, utilizing specific CPT code for lipid panels.

Colorectal Cancer Screening

All Medicare beneficiaries aged 50+ are eligible; various tests have specific age and frequency guidelines.

High-Risk Criteria for Colorectal Cancer

Past colorectal cancer, family history, and inflammatory bowel disease increase risk for regular screenings.

Intensive Behavioral Therapy for Cardiovascular Disease

Focuses on risk reduction, covered annually with specific counseling aspects included.

Medicare Non-Covered Services

Includes long-term care, most dental care, cosmetic surgery, hearing aids, routine foot care, etc.

Provider Contracting Options with Medicare

Providers can participate in PAR agreements to accept Medicare's allowed charges or may opt out entirely.

Incident-to Services Guidelines

Services must be part of ongoing treatment and under direct physician supervision; applicable only in outpatient settings.### Incident-to Services
Non-Physician Practitioners (NPPs) include Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Clinical Psychologists, Clinical Social Workers, and Certified Nurse Midwives.
Claims for incident-to services can be billed under the supervising physician’s name, allowing for 100% reimbursement.
NPP services not billed as incident-to will be reimbursed at 85% using their own NPI numbers.

Claim Submission Requirements

Incident-to claims should be submitted under the supervising physician present at the time of service to avoid audit complications.
Providers must possess a National Provider Identifier (NPI), a unique 10-digit number required by HIPAA to prevent fraud.

NPI Application Info

Essential information for an NPI application includes the provider's credentials, personal information, business addresses, and any existing provider identification numbers.
NPI applications can be submitted through the NPPES website.

Council for Affordable Quality Healthcare (CAQH)

CAQH is a nonprofit that centralizes provider credentialing data for use across multiple health plans.

Advanced Beneficiary Notice (ABN)

An ABN is a written notice to Medicare patients when a provider believes Medicare may not cover a service.
Issuing an ABN is crucial when care might be considered custodial, exceeding therapy caps, or when a patient does not meet eligibility requirements.

Medicare and Medically Necessary Services

"Medically Necessary" services must be reasonable, necessary for diagnosis or treatment, and not specifically excluded under Medicare provisions.

Additional Guidelines for ABNs

Specific guidelines exist for hospices, home health agencies, and durable medical equipment suppliers regarding ABNs.
ABNs are not required for excluded services and must follow a standardized format, limited to one page.

Cost Estimates in ABNs

Providers must provide a good-faith estimate of costs for services potentially not covered, aiming within a margin of $100 or 25% of actual costs.

Patient Options on ABNs

Patients can choose to accept financial responsibility for non-covered services, which can affect claims submission and potential refunds from insurers.

Claim Submission and Medicare Timeliness

Medicare claims must be filed within 12 months after the date of service, with no exceptions for timely filing documented.
Certain administrative errors and retroactive situations may grant extensions for filing.

Submission of Claims

Claims must typically be submitted electronically under the Administration Simplification Compliance Act, unless specific exceptions apply (e.g., small providers).

Common Medicare Denials

Claims can be denied for issues such as incorrect patient identification, use of invalid or truncated diagnosis codes, and non-matching codes.

Medicare Appeals Process

Minor errors on claims may be corrected without formal appeal; incomplete or invalid claims are returned with explanations for correction or re-submission.### Claim Reopening and Appeals Process
Providers can request a reopening of processed claims to rectify clerical errors like data entry mistakes or misapplied fee schedules.
common clerical errors include mathematical mistakes, transposed codes, and misapplied duplicate denials.
Reopenings can be initiated via telephone with specific patient and provider details required.
Medicare (Parts A and B) offers a five-level claims appeal process, all appeals must be submitted in writing.

Levels of Medicare Claims Appeal Process

Level 1 – Redetermination: Must be filed within 120 days of receiving the remittance advice (RA). It uses CMS-20027 and results in a decision sent within 60 days.
Level 2 – Reconsideration: If unsatisfied with the redetermination, a request must be filed within 180 days. It uses CMS-20033 and decisions are typically sent within 60 days.
Level 3 – Administrative Law Judge (ALJ): Requests must be made within 60 days; a hearing request form is OMHA-100. Decisions issued within 90 days of request.
Level 4 – Appeals Council: No financial threshold requirement; requests must be submitted within 60 days and decisions usually within 90 days.
Level 5 – Judicial Review: Requests can be made within 60 days of receiving the Appeals Council's decision.

Required Elements for Redetermination and Reconsideration

Level 1: Requires details like beneficiary's name, Medicare number, services/items involved, service dates, and signature of the requester.
Level 2: Similar requirements as Level 1 with additional information regarding the contractor who made the prior decision.

Tips for Filing Appeals

Consolidate similar claims into one appeal starting at Level 1.
Timeliness is essential: file requests promptly with the appropriate contractor.
Include all previous decision letters and relevant documentation like appointment of representative forms.
Communicate promptly and ensure the appeal request is signed.

Medicare Payment Regulations

A physician who opts out of Medicare can charge any amount for services rendered; patients are liable for full charges.
An Advance Beneficiary Notice (ABN) must be signed before services are rendered to allow for potential balance billing.
Medicare claims must be filed within 12 months from the date of service, as mandated by the ACA.

Medicaid Overview

CHIP stands for Children's Health Insurance Program, aimed at aiding children's healthcare access.
Medicaid eligibility aligns with federal poverty levels, verified monthly at each patient visit.
Medicaid is regarded as the payer of last resort; other payers must be billed before Medicaid.

Common Denials in Medicaid Claims

Denials may occur due to recipient ineligibility, being covered by another payer, frequency service limits, or invalid diagnosis codes.

Medigap and Supplemental Insurance

Medigap policies help cover costs not paid by Original Medicare but do not generally cover prescription drugs or long-term care.
Medigap insurance must conform to federal minimum standards and is identified by letters A through N.

TRICARE Programs

TRICARE is a healthcare program designed for military families and retirees, previously known as CHAMPUS.
TRICARE for Life provides Medicare-wrap coverage, automatically enrolling eligible members.
TRICARE Select is a fee-for-service plan enabling enrollees to see any TRICARE-authorized provider with associated costs.

CHAMPVA Eligibility and Coverage

CHAMPVA covers spouses and children of veterans with specific service-connected disabilities but not eligible for TRICARE.
CHAMPVA pays 75% of the allowable amount for outpatient services, providing fee-for-service insurance without requiring a primary care manager.

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Description

Test your knowledge on TRICARE Young Adult options with these flashcards from Chapter 11. This quiz covers eligibility requirements and different plans available for young adults, ensuring you understand the key concepts. Perfect for students and professionals in healthcare management.