Medicare Chapter 9 Flashcards

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Questions and Answers

What does the term 'Advance Beneficiary Notice of Noncoverage (ABN)' refer to?

A type of claim submitted for Medicaid

A form used to inform a patient of potential non-reimbursement (correct)

An insurance policy for elderly patients

A list of Medicare-approved drugs

What are carriers in the context of health insurance?

Health plan; also known as insurance company, payer, or third-party payer.

What is the Correct Coding Initiative (CCI)?

Computerized Medicare system of CPT code edits to prevent overpayment for procedures.

What is a crossover claim?

Claim for services to a Medicare/Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer. Signup and view all the answers

What does a fiscal intermediary do?

Processes claims for government programs; for Medicare, the FI processes Part A claims. Signup and view all the answers

What is a formulary?

A list of a health plan's selected drugs and their proper dosages. Signup and view all the answers

What is hospice?

A public or private organization that provides services for terminally ill people and their families. Signup and view all the answers

In Medicare, the highest fee that nonparticipating physicians may charge for a particular service is called the ______.

limiting charge Signup and view all the answers

What is a Local Coverage Determination (LCD)?

Policies issued by Medicare to clarify medical necessity issues. Signup and view all the answers

What is a Medical Savings Account (MSA)?

The Medicare health savings account program. Signup and view all the answers

What are medically unlikely edits (MUEs)?

CMS unit-of-service edits that check for clerical or coding errors. Signup and view all the answers

What is Medicare?

The federal health insurance program for people 65 or older and some people with disabilities. Signup and view all the answers

What is a Medicare Administrative Contractor (MAC)?

New entities assigned by CMS to replace Part A fiscal intermediaries and Part B carriers. Signup and view all the answers

What is Medicare Advantage?

Medicare plans other than the Original Medicare Plan. Signup and view all the answers

Who is a Medicare beneficiary?

A person covered by Medicare. Signup and view all the answers

What is the Medicare Fee Schedule (MFS)?

The RBRVS-based allowed fees that are reimbursable to Medicare participating physicians. Signup and view all the answers

What is the Medicare Modernization Act (MMA)?

Short name for the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Signup and view all the answers

What is Medicare Part A?

The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care. Signup and view all the answers

What does Medicare Part B cover?

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. Signup and view all the answers

What is Medicare Part C?

Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program. Signup and view all the answers

What is Medicare Part D?

Prescription drug reimbursement plans offered to Medicare beneficiaries. Signup and view all the answers

What is a Medicare Remittance Notice (MRN)?

Remittance advice from Medicare to providers that explains how payments for a batch of Medicare claims were determined. Signup and view all the answers

What is a Medicare Summary Notice (MSN)?

Type of remittance advice from Medicare to plan beneficiaries to explain how their benefits were determined. Signup and view all the answers

What is Medigap?

Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage. Signup and view all the answers

What is a Medi-Medi beneficiary?

Person who is eligible for both Medicare and Medicaid benefits. Signup and view all the answers

What does a national coverage determination (NCD) do?

Issued by Medicare to help clarify medical necessity issues. Signup and view all the answers

What is the Original Medicare Plan?

The Medicare fee-for-service plan. Signup and view all the answers

What is the Physician Quality Reporting Initiative (PQRI)?

A CMS program that provides a potential bonus for performance by physicians on selected measures addressing quality of care. Signup and view all the answers

What is a primary payer?

Insurance billed first. Signup and view all the answers

Study Notes

Medicare Terms and Definitions

Advance Beneficiary Notice of Noncoverage (ABN): Form informing patients that a service may not be reimbursed by Medicare.
Carriers: Entities managing health plans, also referred to as insurance companies or third-party payers.
Correct Coding Initiative (CCI): Medicare system that employs computerized CPT code edits to prevent overpayment for medical procedures.
Crossover Claim: Claim for services where Medicare is the primary payer, which is transmitted to Medicaid as the secondary payer.
Fiscal Intermediary (FI): Government contractor processing Medicare claims, specifically for Part A.
Formulary: A comprehensive list of approved medications and dosages covered by a health plan.
Hospice: Organizations that provide care for terminally ill individuals and support for their families.
Limiting Charge: Maximum fee nonparticipating physicians can charge, limited to 115% of the Medicare Fee Schedule.
Local Coverage Determination (LCD): Medicare policies clarifying issues of medical necessity.
Medical Savings Account (MSA): Health savings account program established by Medicare.
Medically Unlikely Edits (MUEs): CMS checks to identify clerical or software billing errors based on service units.
Medicare: Federal health insurance program catering to individuals aged 65 and older, and certain disabled people.
Medicare Administrative Contractor (MAC): Entities managing claims for Parts A and B, replacing fiscal intermediaries and Part B carriers.
Medicare Advantage: Alternative Medicare plans outside the Original Medicare framework.
Medicare Beneficiary: Individuals who are covered by Medicare insurance.
Medicare Fee Schedule (MFS): Set of reimbursable fees based on RBRVS for Medicare participating physicians.
Medicare Modernization Act (MMA): Legislation that includes provisions from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Medicare Part A: Covers hospitalization, skilled nursing facility care, home health care, and hospice services.
Medicare Part B: Provides coverage for physician services, outpatient care, durable medical equipment, and supplies.
Medicare Part C: Medicare Advantage plans providing managed care options to beneficiaries.
Medicare Part D: Plans designed for prescription drug reimbursement for Medicare beneficiaries.
Medicare Remittance Notice (MRN): Document providing details on payment determinations for Medicare claims.
Medicare Summary Notice (MSN): Remittance advice explaining benefit determinations to plan beneficiaries.
Medigap: Supplemental insurance plans offered by private carriers to enhance Original Medicare coverage.
Medi-Medi Beneficiary: Individuals eligible for both Medicare and Medicaid benefits.
National Coverage Determination (NCD): Medicare-issued guidelines to clarify medical necessity.
Original Medicare Plan: Traditional fee-for-service Medicare program.
Physician Quality Reporting Initiative (PQRI): CMS program offering potential bonuses to physicians based on quality care measures.
Primary Payer: The insurance that is billed first for services rendered.

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Test your knowledge with these flashcards on Medicare terminology from Chapter 9. Each card provides a key term along with its definition to help reinforce your understanding of Medicare coverage and policies. Perfect for students and professionals preparing for exams or refreshing their knowledge.