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Questions and Answers
The timely filing period for claims for Part B providers under the Affordable Care Act is _____.
The timely filing period for claims for Part B providers under the Affordable Care Act is _____.
Within one calendar year after the date of service
As a result of Medicare issuing about _____ in payments per year with significant amounts of improper payments, the Medicare Integrity Program was enacted.
As a result of Medicare issuing about _____ in payments per year with significant amounts of improper payments, the Medicare Integrity Program was enacted.
- $5 billion
- $3 trillion
- $100 million
- $500 billion (correct)
Lab work may be performed at which of the following locations?
Lab work may be performed at which of the following locations?
- Ambulatory surgery centers
- Physician's offices (correct)
- Urgent care facilities
- Off-site labs (correct)
What should a provider do if a claim has not been paid after thirty days?
What should a provider do if a claim has not been paid after thirty days?
Services of allied health professionals provided under the physician's direct supervision that may be billed under Medicare are called _____.
Services of allied health professionals provided under the physician's direct supervision that may be billed under Medicare are called _____.
What should practices do if covered and noncovered services are performed for a patient on the same date?
What should practices do if covered and noncovered services are performed for a patient on the same date?
Which of the following statements are true about roster billing?
Which of the following statements are true about roster billing?
All lab work for Medicare patients is regulated by _____ rules.
All lab work for Medicare patients is regulated by _____ rules.
What does the Medicare assignment code C indicate?
What does the Medicare assignment code C indicate?
When is an insurance type code required?
When is an insurance type code required?
Which of the following medical staff members perform incident-to services?
Which of the following medical staff members perform incident-to services?
If a patient is covered by Medicare and a Medigap plan, Medicare will ________ send a claim to Medigap for secondary payment.
If a patient is covered by Medicare and a Medigap plan, Medicare will ________ send a claim to Medigap for secondary payment.
What is the name of a simplified billing process for vaccines?
What is the name of a simplified billing process for vaccines?
The Medicare assignment code _____ indicates the provider accepts Medicare assignment.
The Medicare assignment code _____ indicates the provider accepts Medicare assignment.
Which insurance type code is used to identify an auto insurance policy as the primary payer?
Which insurance type code is used to identify an auto insurance policy as the primary payer?
If a patient is covered by Medicare and a Medigap plan, how many claims are sent to Medicare?
If a patient is covered by Medicare and a Medigap plan, how many claims are sent to Medicare?
The Medicare program is managed by ______________.
The Medicare program is managed by ______________.
Which of the following individuals would be eligible to receive Medicare benefits?
Which of the following individuals would be eligible to receive Medicare benefits?
Medicare Part A is also called _____.
Medicare Part A is also called _____.
If enrollment in Part B takes place more than twelve months after a person's initial enrollment period, there is a _____ percent increase in the premium for each year the beneficiary failed to enroll.
If enrollment in Part B takes place more than twelve months after a person's initial enrollment period, there is a _____ percent increase in the premium for each year the beneficiary failed to enroll.
In which of the following areas were changes made to Medicare as a result of the Medicare Modernization Act?
In which of the following areas were changes made to Medicare as a result of the Medicare Modernization Act?
What is the federal medical insurance program established in 1965 under Title XVIII of the Social Security Act?
What is the federal medical insurance program established in 1965 under Title XVIII of the Social Security Act?
What benefits are offered under the Medicare Advantage Plus Prescription Drug plan?
What benefits are offered under the Medicare Advantage Plus Prescription Drug plan?
A retired federal employee who is over the age of sixty-five and enrolled in Civil Service Retirement System (CSRS) is eligible for _____.
A retired federal employee who is over the age of sixty-five and enrolled in Civil Service Retirement System (CSRS) is eligible for _____.
What is the Medicare number most often called?
What is the Medicare number most often called?
Most people eligible for Medicare Part A do not pay a premium for coverage if they or their spouse has _____ quarters of Medicare-covered employment.
Most people eligible for Medicare Part A do not pay a premium for coverage if they or their spouse has _____ quarters of Medicare-covered employment.
What is the role of Medicare administrative contractors?
What is the role of Medicare administrative contractors?
Which of the following services are covered under Medicare Part B?
Which of the following services are covered under Medicare Part B?
When was the Medicare Modernization Act enacted?
When was the Medicare Modernization Act enacted?
How much is the coinsurance for physicians' services covered under Medicare Part B?
How much is the coinsurance for physicians' services covered under Medicare Part B?
What benefits are provided to eligible members under Medicare Part D?
What benefits are provided to eligible members under Medicare Part D?
What determines the services that are covered under Medicare?
What determines the services that are covered under Medicare?
Which of the following elements are found on a Medicare card?
Which of the following elements are found on a Medicare card?
Upon enrollment in the Medicare program, providers are issued a(n) _____.
Upon enrollment in the Medicare program, providers are issued a(n) _____.
The Medicare Modernization Act required Medicare to replace the Part A fiscal intermediaries and Part B contractors with _____.
The Medicare Modernization Act required Medicare to replace the Part A fiscal intermediaries and Part B contractors with _____.
Providers located in HPSAs are eligible for _____ percent bonus payments from Medicare.
Providers located in HPSAs are eligible for _____ percent bonus payments from Medicare.
Which of the following services are a covered benefit under Medicare Part B?
Which of the following services are a covered benefit under Medicare Part B?
MPFS was developed from the _____ system.
MPFS was developed from the _____ system.
Which of the following services are excluded under Medicare?
Which of the following services are excluded under Medicare?
Participating providers may bill patients for services that are excluded from the Medicare program with a written notification called a(n) _____.
Participating providers may bill patients for services that are excluded from the Medicare program with a written notification called a(n) _____.
What is the purpose of the PTAN?
What is the purpose of the PTAN?
On the ABN form, blanks A-C comprise the _____.
On the ABN form, blanks A-C comprise the _____.
What is an HPSA?
What is an HPSA?
Which of the following types of descriptors may be used in Blank D on the ABN form?
Which of the following types of descriptors may be used in Blank D on the ABN form?
Which of the following are true under Medicare Part B?
Which of the following are true under Medicare Part B?
How many choices are listed in Blank G?
How many choices are listed in Blank G?
What are payment arrangements for Medicare PAR providers?
What are payment arrangements for Medicare PAR providers?
The provider may use Blank _____ to provide additional clarification that the provider believes will be of use to the patient.
The provider may use Blank _____ to provide additional clarification that the provider believes will be of use to the patient.
Which form did the voluntary ABN replace?
Which form did the voluntary ABN replace?
What do ABN modifiers indicate?
What do ABN modifiers indicate?
Who completes the Header section of the ABN?
Who completes the Header section of the ABN?
How much are providers paid by Medicare who elect not to participate in the Medicare program but who accept assignment on a claim?
How much are providers paid by Medicare who elect not to participate in the Medicare program but who accept assignment on a claim?
Blanks D-F on the ABN form are part of the _____ section.
Blanks D-F on the ABN form are part of the _____ section.
Under the Medicare limiting charges clause, non-PAR providers may not charge a Medicare patient more than _____ percent of the fee listed in the non-PAR MFS.
Under the Medicare limiting charges clause, non-PAR providers may not charge a Medicare patient more than _____ percent of the fee listed in the non-PAR MFS.
The Options Box section on the ABN form must be filled in by the _____.
The Options Box section on the ABN form must be filled in by the _____.
What is an MSN?
What is an MSN?
How many blanks are part of the Additional Information section of the ABN?
How many blanks are part of the Additional Information section of the ABN?
What percentage of all Medicare beneficiaries are enrolled in group managed care plans called Medicare Advantage and Medicare Part C?
What percentage of all Medicare beneficiaries are enrolled in group managed care plans called Medicare Advantage and Medicare Part C?
What should be appended to CPT/HCPCS codes on Medicare claims when an ABN has been signed?
What should be appended to CPT/HCPCS codes on Medicare claims when an ABN has been signed?
What are the most restrictive plans of the Medicare CCP plans?
What are the most restrictive plans of the Medicare CCP plans?
Non-PAR providers decide whether to accept assignment on a ________ basis.
Non-PAR providers decide whether to accept assignment on a ________ basis.
Under a Medicare private fee-for-service plan, patients receive services from _____.
Under a Medicare private fee-for-service plan, patients receive services from _____.
What are non-PAR physicians subjected to under the Medicare payment guidelines?
What are non-PAR physicians subjected to under the Medicare payment guidelines?
What does the Medical Savings Account pay for under the Medicare Advantage plan?
What does the Medical Savings Account pay for under the Medicare Advantage plan?
Which former form does the MSN replace?
Which former form does the MSN replace?
_____ are private insurance plans that beneficiaries may purchase to cover the unpaid amounts in Medicare coverage.
_____ are private insurance plans that beneficiaries may purchase to cover the unpaid amounts in Medicare coverage.
A(n) _____ is responsible for providing all Medicare-covered services except hospice care in return for predetermined capitated payment.
A(n) _____ is responsible for providing all Medicare-covered services except hospice care in return for predetermined capitated payment.
A(n) _____ plan is a plan an individual may receive when retiring from a company.
A(n) _____ plan is a plan an individual may receive when retiring from a company.
Which of the following are Medicare coordinated care plans?
Which of the following are Medicare coordinated care plans?
Medicare requires the use of the _____ for coding services.
Medicare requires the use of the _____ for coding services.
Who operates the Medicare private fee-for-service plan?
Who operates the Medicare private fee-for-service plan?
Which modifier does the principal physician of record use with the E/M code when billed?
Which modifier does the principal physician of record use with the E/M code when billed?
_____ created a new plan for Medicare called a Medical Savings Account.
_____ created a new plan for Medicare called a Medical Savings Account.
Which federal legislation changed the timely filing period for Medicare Part B claims?
Which federal legislation changed the timely filing period for Medicare Part B claims?
Which of the following are gaps paid by Medigap plans?
Which of the following are gaps paid by Medigap plans?
What is the purpose of the Medicare Integrity Program?
What is the purpose of the Medicare Integrity Program?
What type of benefits do supplemental insurance plans provide?
What type of benefits do supplemental insurance plans provide?
When are CCI updates issued?
When are CCI updates issued?
Medicare defines _____ as those sent to one or more Medicare contractors from the same provider for the same beneficiary, the same service, and the same date of service.
Medicare defines _____ as those sent to one or more Medicare contractors from the same provider for the same beneficiary, the same service, and the same date of service.
In 2010, Medicare stopped paying for all consultation CPT codes from the _____ section except for G-codes.
In 2010, Medicare stopped paying for all consultation CPT codes from the _____ section except for G-codes.
Under what conditions should practices split the bill when preparing claims?
Under what conditions should practices split the bill when preparing claims?
What is the timely filing period for claims for Part B providers under the Affordable Care Act?
What is the timely filing period for claims for Part B providers under the Affordable Care Act?
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Study Notes
Medicare Administration and Eligibility
- Managed by the Centers for Medicare and Medicaid Services (CMS).
- Eligible individuals include those over sixty-five, individuals receiving Social Security disability benefits, and those under sixty-five receiving dialysis.
- Medicare Part A is also referred to as hospital insurance.
- Most individuals eligible for Medicare Part A do not pay a premium if they or their spouse have forty quarters of Medicare-covered employment.
Enrollment and Premiums
- If enrollment in Part B exceeds twelve months after the initial enrollment period, a 10% premium increase occurs for each year of delay.
- Medicare beneficiaries may receive benefits under the affordable Medicare Advantage plans, combining various services.
Medicare Parts Overview
- Medicare Part B covers medical equipment, medical supplies, and physician services, among other benefits.
- Coinsurance for physicians' services under Part B is 20%.
- Medicare Part D provides prescription drug coverage.
Legislation and Reform
- The Medicare Modernization Act was enacted in 2003, introducing improvements such as better benefits for Part C enrollees.
- Federal legislation determines services covered under Medicare, including guidelines for claims.
Claims and Billing Procedures
- Medicare administrative contractors manage claims for Parts A and B.
- Providers in Health Professional Shortage Areas (HPSAs) receive a 10% bonus payment from Medicare.
- Providers can bill patients for non-covered services under a written notification noted as a voluntary ABN.
Coverage Exclusions and Limitations
- Services excluded from Medicare include acupuncture, eye refraction, and self-administered medications.
- NonPAR providers may charge patients up to 115% of the fee listed in the nonPAR MFS under the limiting charges clause.
Supplemental Insurance and Payment Arrangements
- Medigap plans help cover expenses such as deductibles and coinsurance that Medicare does not fully cover.
- PAR providers must accept charge amounts listed in the Medicare Physician Fee Schedule as their total payment.
Administrative Guidance and Patient Information
- ABN forms are crucial for informing patients about potential costs and services not covered by Medicare.
- Relevant sections of ABN forms include the Header, Body, and Options Box, which indicate what services may not be covered.
Audit and Compliance
- The Medicare Integrity Program aims to identify and tackle fraud, waste, and abuse.
- Timely filing limits for claims have changed under the Affordable Care Act, requiring filing within one calendar year after service.
Miscellaneous
- All Medicare beneficiaries are eligible for services from Medicare-approved providers under various plans.
- Services of allied health professionals billed under direct supervision are termed incident-to services.
- When both covered and noncovered services are performed on the same date, practices must split the bill for appropriate billing.
Vaccinations and Billing Practices
- Medicare covers vaccinations for influenza and pneumococcal diseases, and claims do not need to be sent electronically.### Medicare Coverage and Claims Processing
- Vaccinations for influenza and pneumococcal are covered by Medicare without requiring annual Part B deductibles.
- Claims for these vaccinations can be submitted non-electronically.
Clinical Laboratory Regulations
- All lab work for Medicare patients is governed by Clinical Laboratory Improvement Amendments (CLIA) rules.
Medicare Assignment Code
- The Medicare assignment code "C" indicates that the assignment is not assigned.
Insurance Type Code Requirements
- An insurance type code is required when a claim is sent to Medicare while Medicare is not the primary payer.
Incident-to Services Providers
- Incident-to services can be performed by physician assistants and nurse-practitioners.
Medigap and Medicare Claims
- Medicare automatically sends claims to a Medigap plan for secondary payment if the patient has both Medicare and Medigap coverage.
Simplified Billing for Vaccines
- Roster billing is a simplified process used for the billing of vaccines.
Timely Filing for Part B Claims
- Claims for Part B providers must be filed within one calendar year after the date of service as per the Affordable Care Act.
Medicare Assignment Code Identification
- The Medicare assignment code "A" signifies that the provider accepts Medicare assignment.
Primary Payer Identification
- The insurance type code "AP" is utilized to identify an auto insurance policy as the primary payer.
Medicare Claims Submitted by Patients with Medigap
- Only one claim is sent to Medicare when a patient is covered by both Medicare and a Medigap plan.
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