CPB Chapter 11 Flashcards

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.