Insurance Handbook for the Medical Office Ch. 13 & 14

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When did federal participation in providing needy persons with medical care begin?

between 1933 and 1935 when the Emergency Relief Administration made funds available to pay the medical expenses of the needy unemployed.

Which act set up the public assistance programs?

the Social Security Act of 1935

In 1950 Congress passed a law mandating what?

that all states set up a health care program of assistance (meaning that the states had to meet minimum requirments).

As a result of Congress' mandate, what happened?

the states set up Medicaid (MCD) programs.

Congress authorized vendor payments for what?

medical care - payments from the wlefare agency directly to physicians, health care institutions, and other providers of medical services.

A new category of assistance receipient was established for who?

the medically needy aged population

Who is the medically needy aged population?

inidividuals whose incomes are too high to qualify them for cash assistance payments, but they need help inmeeting the costs of medical care.

Since 1983, what has been the trend inmany states?

to expand Medicaid eligibility and services

What does DEFRA stand for?

Deficit Reduction Act of 1984

What does CHAP stand for?

Child Health Assurance Program

Who administers Medicaid?

state governments with partial federal funding

Who is responsible for the federal aspects of Medicaid?

CMS (center for Medicaid and Medicare Services); the STATE

What does SCHIP stand for?

State Children's Health Insurance Program

SCHIP is supported under?

Title V of the Social Security Act

What act allowed for qualified Medicare beneficiaries (QMBs)?

the 1991 Omnibus Budget Reconciliation Act

Who are qualified Medicare beneficiaries?

individuals who are aged and disabled and are receiving Medicare and have annual incomes below the federal poverty level.

Medicaid is available for who?

certain needy and low-income people such as the elderly (65 years or older), blind, disabled, and members of families with dependent children (deprived of the support of at least one parent) and financially eligible on the basis of income and resources

What group is eligible for Medicaid Benefits?

the Aged and Disabled

What does MCHP stand for?

Maternal and Child Health Program

What specific conditions qualify children for benefits under the MCHP?

all state laws include children who have some kind of handicap that requires orthopedic treatment or plastic surgery; a few states add other conditions

How long can a patient participate in the Medicaid program?

a patient could be on Medicaid for one month or several months at a time; each case is different.

What must a physician do if he agrees to take Medicaid patients?

accept the Medicaid allowance as payment in full.

What is the Medicaid allowance?

the maximum dollar amount to be considered for payment for a service or procedure by Medicaid.

What should be done with the patient's identification card each time they visit the office?

the expiration date should be checked,you should note if the patient has other insurance, copayment requirments, or restrictions such as being eligible for only certain types of medical services

Point-of-service Machines: When professional services are rendered what must be done?

eligibility for that month must be verified.

What is the EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)?

a program of prevention, early detection, and treatment of welfare children.

Why was Medicaid Managed Care established?

to control escalating health care costs by curbing unnecessary emergency department visits and emplasizing preventative care.

When may Prior approval be needed?

it is necessary for various services except a bona fide emergency

What do you do when filing a claim for a Medicaid managed care patient?

send the bill or claim form to the managed care organization (MCO) and nto Medicaid

When Medicare and a third-party payer cover a patient, who is billed first?

the third-party payer (other insurance) is billed first. Medicaid is ALWAYS considered a last resort.

What is the time limit to appeal a claim?

it varies from state to state, but it is usually 30 to 60 days from the date listed on the Remittance Advice

What does CHAMPUS stand for?

Civilian Health and Medical Program of the Uniformed Services

What is CHAMPUS?

a federally funded comprehensive health benefits program created by Congress.

Who is not elilgible for TRICARE?

the CHAMPVA beneficiaries

Who can be enrollees of CHAMPUS?

dependents of personnel who are actively serving in the armed services and military retirees and their dependents.

CHAMPUS was renamed what?

TRICARE in January 1994

What are the TRICARE choices?

TRICARE Standard, TRICARE Extra, and TRICARE Prime

Define service retiree or military retiree

peopel who are retired from a career in the armed forces and remain in TRICARE until the age of 65, when they obtain Medicare.

What does NAS stand for?

Nonavailability Statement

What is NAS?

a certification from a military hospital stating that they cannot provide the needed care.

What is a catchment area?

a specific geographic region defined by ZIP code based on area of 40 miles surrounding each MTF (Military Treatment Facility)

What is cooperative care?

services or supplies that may be cost shared by TRICARE Standard under certain conditions.

When is the TRICARE fiscal year?

begins October 1 and ends September 30.

Who is an authorized provider

a physician or other individual authorized provider of care or a hospital or supplier approved by TRICARE to provide medical care and supplies

List 4 examples of an authorized provider

1) Doctor of Medicine MD (2) Doctor of Osteopathy DO or MD (3) Doctor of optometry DO (4) Psychologist

What is an HCF?

a health care finder

What does an HCF do?

assist with the referral or preauthorization request, when services are not available. Helps the patient work with their PCP to locate a specialist or get preauthorization for care.

Who is a HCF?

a health care professional, usually a registered nurse

What is TRICARE Prime?

a voluntary health maintenance organization (HMO) type option.

How do you enroll in TRICARE Prime?

by completing an application and agreeing to enroll for a minimum of 12 months as a member.

What is a PCM in TRICARE?

a primary care manager that the beneficiary can choose or be assigned for each family member.

What does the PCM do?

manages all aspects of the patient's health care (except emergencies) including referrals to specialists.

What act created CHAMPVA?

the Veterans Health Care Expansion Act of 1973

What is CHAMPVA?

a CHAMPUS-like program that became effective on September 1, 1973.

What does CHAMPVA stand for?

Civilian Health and Medical Program of the Veterans Administration.

CHAMPVA is considered a service benefit program which means what?

that there are no premiums.

When is the wife of a service disabled person due to a work related injury eligible for CHAMPVA?

when she is not eligible for TRICARE or Medicare Part A as a result of reaching age 65.

What did the Privacy Act of 1974 do?

establish an individual's right to review his/her medical record and to contest inaccuracies in medical records..

the Privacy Act of 1974 is maintain by who?

by a federal medical facility such as a VA medical center or US Public Health Service facility

How do providers submit claims with TRICARE Extra or TRICARE Prime?

electronically with a 837P claim to TRICARE subcontractors for services given.

What is the time limit to file claims with TRICARE Extra/Prime?

a 1 year deadline applies to each item on the claim

By law, when is TRICARE/CHAMPVA the secondary payer?

when a beneficiary is enrolled in other health insurance (OHI) or a civilian health plan.


inflammatory bowel disease


infectious disease


lethal dose


lumbar puncture


living and well


left eye


opening; bone


both eyes


vital signs; versus


ultrasound, ultrasonography

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