Medical insurance Final on ch 3,6,7,11,13,14

Print this FlashCard
Question Answer
What is a set of ethical standards designed to protect patients? Patient Bill of Rights
What is a list of medical services covered under the insured’s policy? Covered services
What are the basic provisions of a managed care contract? Everything expected of the provider,time limits for submitting claims,and reimbursement amounts
What types of data are reported using ICD-10-CM codes? Procedures
Who maintains ICD-10-PCS? cms
What agency maintains the ICD-10-CM? NCHS
Who is responsible for the partial freeze on changes to ICD-9 and ICD-10 codes? C&M
What was the original date established by the DHHS for implementation of ICD-10-CM in the U.S.? October 1st,2013
Who published CPT? (AMA) American Medical Association
CPT codes are implemented each year when? January 1st
Know the SIX (6) sections of the CPT manual 1)Evaluation and management2)Anesthesia3)Surgery4)Radiology5)Pathology and Laboratory6)Medicine
Modifier 32 mandated services
modifier 52 reduced services
modifier 57 decision for surgery
What are the three key components to select the appropriate E/M code? 1)patient history2)examination3)MDM (Medical decision making)
What are the FOUR (4) types of histories used in determining the levels of E/M services? 1)problem focused2)expanded problem-focused3)detailed4)comprehensive
What organization enrolls new Medicare beneficiaries in to the program? SSA-Social security Administration
What are the 4 (four) most common types of Medicare fraud? 1)up coding2)billing for services not done3)misrepresenting a diagnosis to justify a payment4)_making false certificates for medically necessity
What are the 3 (three) groups eligible for Medicaid benefits? 1)categorically needy2)medically needy3)special groups
What is the role of a Primary Care Manager under TRICARE Prime? coordinates and manages the patients medical care
What are 3 health plans available to individuals who are eligible for TRICARE benefits? TRICARE PrimeTRICARE remoteTRICARE StandardTRICARE for Life
contracted services covered service provided by the physician or other healthcare provider
coordination of benefits allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities
crosswalk reference that compares data from one program to another
mapping reflects the complexity of the code sets rather than oversimplifying
NCHS National center for health statistics
GEM General equivalence mapping
CMS Centers for medicaid and medicare
EPSDT Early and periodic screening,diagnostic,and treatment
AAPC American academy of professional coders
Modifier added on to a code if something else was done
modifier factors ex-ice pack,blood test,x-ray-add ons
ADD on code +
New code triangle
revised code O
reinstated or recycled code bow tie
Medicare part A Hospital insurance—inpatient services
Medicare Part B Physician services—–out patient services
Medicare part C Medicare advantage and must have part A&B
Medicare part D Medication only
CHIPRA Children's health insurance program re authorization act—covers low to moderate income houses who dont have insurance
TANF Temporary assistance for needy families
Medicare fraud knowingly and intentionally executing a plan to defraud or scheme a healthcare benefit program
medicare abuse improper payment for services not rendered
CHAMP VA for retired military
TRICARE prime HMO plan routine services and is assigned a primary care manager
TRICARE extra PPO Plan allows a military person to get service at a treatment facility from a civilian provider at a reduced price
TRICARE standard FFS plan for active duty family's and retirees that goes in affect when a civilian provider treats them–pays a annual deductable
NAS-Nonavailability statement obtained by DEERS and is so you can be treated by a civilian provider/non military facility
Beneficiary person eligible to receive benefits under a insurance policy
sponsor beneficiary or policyholder for TRICARE plan

Leave a Reply

Your email address will not be published. Required fields are marked *