Billing & Coding

Created by denisemb62 

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Medicaid provides medical and health realated services to individuals and families with low incomes.

True

States are not required to provide Medicaid coverage for individuals who receive federally assisted incomeaintenance payments.

False

Each state administers its own Medicaid program, and AMA monitors the programs.

False

States are required to extend Medicaid eligiability to all children born after September 30, 1983 until they reach age 19

True

The BBA allows states to provide 12 months of continuous Medicaid coverage (without reevaluation) for eligible children under the age of 19

True

In Many cases, Medicaid eligibility will depend on the patient's monthly income

True

Retroactive eligibility is never granted to paients who had hight medical expenses prior to filing for Medicaid.

False

States must provide home health services to beneficiaries who are entitled to receive nursing facility services.

True

There is no limit on the amount that a noncontract provider, physician, or other entity cab charge a PACE participant

False

Preauthorization guidelines include elective inpatient admission

True

States may not require nominal deductibles, coinsurance, or copayments for certain services performed.

False

Services covered by both Medicaid and Medicare are first paid by Medicaid and the difference is paid by Medicare

False

The Medicaid eligibilty verifaction system allows providers to electronically access the state's eligibility file

True

Medicaid - covered services must be recognized as the prevailing standard and consistent with generally accepted professional medical standards of the provider's peer group

True

Medically necessary services are furnished primarily for the convenience of the recipient or the provider.

False

The Medicaid program was implemented in the year

1965

What is California's equivalent to the Medicaid program

Medi-Cal

Medicaid is jointly funded by the ______ and _____governments to assist states in providing adequate medical care to qualified individuals

Federal and State

The following would be covered under Medicaid

1. Categorically needy
2. Medically needy
3. Special Groups

What does the acronym TANF

Temporary Assistant to Needy Families

TANF was previously known as

Aid to Families with Dependent Children

Categorically needy Medicaid eligibility groups ARE NOT necessarily entitled to

nursing facility services for individuals under the age of 21

Medicaid operates as a (an) _____payment system

Vendor and fee for service

What type (s) of services are exempt form copayments from Medicaid recipients

Emergency and Family planning

The portion of the Medicaid program paid by the federal government is known as the

Federal Medical Assistance Percentage

The federal government reimburses states _____ of the cost of services provided through facilities of the Indian Health Service

100%

Dual eligibles refers to

Individual entitled to Medicare and eligible for some type of Medicaid services

Medicaid is always either the

Payer of the last resort

Any provider who accepts a Medicaid patient must accept the Medicaid determined payment as

Payment in Full

Providers receive reimbursement from Medicaid on what type of basis

Lump Sum

Spend down to Medicaid Eligibilty

Medically needy

TANF

Cash assistance for children deprived of support

Federal Medical Assistance Percentage

Portion of Medicaid program paid by the federal government

Surveillance and utilization review system

Safeguards against inappropriate use of Medicaid services

SCHIP

State childrens's health insurance program

Payer of last resort

Medicaid program

EPSDT

Routine pediatric checkups for all children enrolled in Medicaid

Medicaid

Medical assistance program for individuals with low income

Mother/baby claim

Services provided to a baby under mother's ID number

PACE

Alternative care for persons aged 55 or older who require nursing faciltiy level care

community Spouse

Spouse who is not in a nursing home

Voided claim

Spouse who is not in a nursing home

Medicaid Remittance advice

Current status of all claims

MCCA

Prevents married couples form being required to spend down

dual eligibles

Individual entitled to Medicare and Medicaid

Part A Covers

Hospital Inpatient, hospice, some home health and Skilled nursong facilities

Part B Covers

Providers , Labs, Outpatient services, (DME) Durable Medical Equipment (Walkers) , therapy, Occupational, Physical , and Speech

Part C (bka) medicare Advantage

Previous Medicare + Choice (HMO, PPO ) 80/20

Part D bka Medicare Prescription Drug Plan

Deducible caovers 75%

Eligibiligy Wrecks 65D

Worked Eligible if they or spouse worked 10 years
Railroad Retirement
ESRD - End Stage Renal Disease (Dialysis)
Civil service retirement a Medicare covered government employment
Kidney donor (during donation)
SS- Social Security
65 yrs, &US Citizens or perm resident
Disabled and on SSDI for 2 years

Qualified Medicare Beneficiary (QMB)

Pays Part A & B pREMIUMS

Specified Low Income Medicare Beneficiary (SLMB) pays

part B Premiums

Qualifying Individual (QI) pays

Part B Premiums

Qualified disable Working Individual QDWI disabled individuals who because of being employed have lost other benefits

States pay their Part A premiums

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