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key terms

An individual becomes eligible for Medicare Parts A and B at age


Medicare Part A is _____ coverage, and Medicare Part B is _____ coverage.

hospital / outpatient

Name an eligibility requirement that would allow aliens to receive Medicare benefits

An applicant must have lived in the United States as a permanent resident for 5 consecutive years

Funding for the Medicare Part A program is obtained from________________________

special contributions from employees and self-employed persons, with employers matching contributions,

and funding for the Medicare Part B program is obtained equally from

those who sign up for Medicare and from the federal government.

Define a Medicare Part A hospital benefit period.

Begins the day a patient enters a hospital and ends when the patient has not been a bed patient in any hospital or nursing facility for 60 consecutive days. It also ends if a patient has been in a nursing facility but has not received skilled nursing care there for 60 consecutive days.

A program designed to provide pain relief, symptom management, and supportive services to terminally ill individuals and their families is known as


Short-term inpatient medical care for terminally ill individuals to give temporary relief to the caregiver is known as

respite care.

The frequency of Pap tests for Medicare patients is

once every 24 months (low risk) and once every 12 months (high risk),

and that for mammograms is

once every 12 months. (Note to instructors: To further eplain this to students, under the Medicare program, mammograms are done for women age 40 and older, plus a one-time baseline mammogram for women 35 to 39 is allowed.)

Some third-party payers offer policies that fall under guidelines issued by the federal government and may cover prescription costs, Medicare deductibles, and copayments; these secondary or supplemental policies are known as

Medigap or Medifill

Name two types of health maintenance organization (HMO) plans that may have Medicare Part B contracts.

a. HMO risk plans
b. HMO cost plans

The federal laws establishing standards of quality control and safety measures in clinical laboratories are known as

the Clnical Laboratory Improvement Amendment of 1988 (CLIA).

Acceptance of assignment by a participating physician means that he or she agrees to ________after the $_____ annual deductible has been met.

accept payment from Medicare (80% of the approved charges) plus payment from the patient (20% of the approved charges), $135

This type of surgery is known as _____because it does not have to be performed immediately.


A Medicare insurance claim form showed a number, J0540, for an injection of 600,000 U of penicillin G. This number is referred to as a/an ________________.

Healthcare Common Procedure Coding System (HCPCS) Level II code number.

Organizations or claims processors under contract to the federal government that handle insurance claims and payments for hospitals under Medicare Part A are known as _______and those that process claims for physicians and other suppliers of services under Medicare Part B are called ____________.

fiscal intermediaries / Medicare administrative contractors (MACs).

A Centers for Medicare and Medicaid Services (CMS)-assigned provider identification number is known as a/an _________.

National Provider Identifier (NPI)

Physicians who supply durable medical equipment must have a/an ________ number.

DME supplier

If circumstances make it impossible to obtain a signature each time a paper claim is submitted or an electronic claim is transmitted, the Medicare patient's signature may be obtained either______________or____________thus indicating the signature is on file.

on a form created by the medical practice / in Block 12 of the CMS-1500 (08-05) claim form

The time limit for sending in a Medicare insurance claim is _________________.

the end of the calendar year after the fiscal year in which services were furnished.

Mrs. Davis, a Medicare/Medicaid (Medi-Medi) patient, has a cholecystectomy. In completing the insurance claim form, the assignment portion is left blank in error. What will happen in this case?

Only Medicare processing will occur, and the payment check will go directly to the patient. Medicaid will not pay.

If an individual is 65 years of age and is a Medicare beneficiary but is working and has a group insurance policy, where is the insurance claim form sent initially?

To the employer-sponsored plan (employee's group health plan).

If a Medicare beneficiary is injured in an automobile accident, the physician submits the claim form to ___________________________

the automobile liability insurance, no-fault insurance, or self-insured liability insurance company.

Medicare prescription drug benefits for individuals who purchase the insurance are available under

d. Medicare Part D

Medicare Secondary Payer (MSP) cases may involve______________________________

a. Medicare aged workers under group health plans of more than 20 covered employees.
b. Medicare aged or disabled individuals who also receive benefits under the Dept. of Veterans Affairs and Medicare.
c. a Medicare patient who is involved in an automobile accident.

If a Medicare patient is to receive a medical service that may be denied payment either entirely or partially, the provider should_________

b. have the patient sign an Advance Beneficiary Notice of Noncoverage form

A decision by a Medicare administrative contractor (MAC) whether to cover (pay) a particular medical service on a contractor-wide basis in accordance with whether it is reasonable and necessary is known as a/an_____________

a. Local Coverage Determination.

According to regulations, a Medicare patient must be billed for a copayment__________________.

c. at least three times before a balance is adjusted off as uncollectible.

All patients who have a Medicare health insurance card have Part A hospital and Part B medical coverage.


Prescription drug plans refer to the drugs in their formularies by tier numbers.


Nonparticipating physicians may decide on a case-by-case basis whether to accept assignment when providing medical services to Medicare patients.


Medicare's Correct Coding Initiative was implemented by the Centers for Medicare and Medicaid Services to eliminate unbundling of CPT codes.


A Medicare/Medigap claim is not called a crossover claim.


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