54 terms

Billing & Coding

Medicaid provides medical and health realated services to individuals and families with low incomes.
States are not required to provide Medicaid coverage for individuals who receive federally assisted incomeaintenance payments.
Each state administers its own Medicaid program, and AMA monitors the programs.
States are required to extend Medicaid eligiability to all children born after September 30, 1983 until they reach age 19
The BBA allows states to provide 12 months of continuous Medicaid coverage (without reevaluation) for eligible children under the age of 19
In Many cases, Medicaid eligibility will depend on the patient's monthly income
Retroactive eligibility is never granted to paients who had hight medical expenses prior to filing for Medicaid.
States must provide home health services to beneficiaries who are entitled to receive nursing facility services.
There is no limit on the amount that a noncontract provider, physician, or other entity cab charge a PACE participant
Preauthorization guidelines include elective inpatient admission
States may not require nominal deductibles, coinsurance, or copayments for certain services performed.
Services covered by both Medicaid and Medicare are first paid by Medicaid and the difference is paid by Medicare
The Medicaid eligibilty verifaction system allows providers to electronically access the state's eligibility file
Medicaid - covered services must be recognized as the prevailing standard and consistent with generally accepted professional medical standards of the provider's peer group
Medically necessary services are furnished primarily for the convenience of the recipient or the provider.
The Medicaid program was implemented in the year
What is California's equivalent to the Medicaid program
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
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
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
State childrens's health insurance program
Payer of last resort
Medicaid program
Routine pediatric checkups for all children enrolled in Medicaid
Medical assistance program for individuals with low income
Mother/baby claim
Services provided to a baby under mother's ID number
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
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