UHI Essential CMS-1500 Claim Instructions Chapter 11

Flashcard maker : Lily Taylor
CMS-1500
the universal claim form
When the Health Care Financing Administration (HCFA) became the centers for Medicare & Medicaid Services (CMS)
July 2001
HCFA means
Health Care Financing Administration
CMS means
Centers for Medicare & Medicaid Services
Who requires all physician to use the cms-1500 form when submitting claims for services provided
Medicare
Blocks 1 through 13
refers to patient information
Blocks 14 through 33
refers to physician information
A clearinghouse
Is an entity that receives transmissions from physicians’ offices, separates the claims by carriers and performs software edit on each claim to check for errors.
Who paid a fee to the clearinghouse for their services
Physicians
After the check process is complete by the clearinghouse,the claim is sent to the proper
insurance carrier
block 1
medicare #, medicaid #, tricare o champus(sponsor ssn), champva (menber id#, group health plan(ssn or id#), Feca blk lung(ssn), other(ID)
block 1a
INSURED ID #
block 2
PATENT NAME(Last Name,First Name, Middle Initial)
block 3
PATIENT BIRTH DATE SEX
block 4
INSURED’S NAME (Last Name, First Name, Middle Initial)
block 5
PATIENT ADDRESS
block 6
PATIENT RELATION SHIP TO THE INSURED
block 7
INSURED’S ADDRESS
block 8
PATIENT STATUS
block 9 a-d
OTHER INSURED’S NAME
a.OTHER INSURED’S POLICY OR GROUP NUMBER
b.OTHER INSURED’S DATE OF BIRTH SEX
c.EMPLYER’S NAME OR SCHOOL NAME
d.INSURANCE PLAN NAME OR PROGRAM NAME
block 10
IS PATIENT CONDITION RELATED TO:
a.EMPLOIMENT?
b.AUTO ACCIDENT?
c.OTHER ACCIDENT?
block 10d
RESERVED FOR LOCAL USE
block 11
INSURED’S POLICY GROUP OR FECA NUMBER
block 11a-d
a.INSURED’S DATE OF BIRTH SEX
b.EMPLOYER’S NAME OR SCHOOL NAME
c.INSURANCE PLAN NAME OR PROGRAM NAME
d.IS THERE ANOTHER HEALTH BENEFIT PLAN?
if yes return to 9a-d
block 12
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE TO RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESARY TO PROCESS THIS CLAIM.I ALSO REQUEST PAYMENT OF GOVERMMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW
SIGNED____________ DATE___________
block 13
INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICES DESCRIBED BELOW
SIGNED_____________
block 14
DATE OF CURRENT ILLNESS (first symptom)OR
MM/DD/YY INJURY(accident)OR
PREGNANCY(LMP)
block 15
IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM/DD/YY
block 16
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
FROM MM/DD/YY TO MM/DD/YY
block 17
NAME OFREFERRING PROVIDER OR OTHER SOURCE
17a.
17b.NPI
block 18
HOSPITALITALIZATION DATES RELATED TO CURRENT SERVICES
FROM MM/DD/YY TO MM/DD/YY
block 19
RESRVED FOR LOCAL USE
block 20
OUTSIDE LAB? CHARGES
block 21
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.__._ 3.__._
2.__._ 4.__._
block 22
MEDICAID RESUMISION
CODE / ORIGINAL REF. NO.
block 23
PRIOR AUTHORIZATION NUMBER
block 24 A-J
A.DATE(S) OF SERVICE
FROM MM/DD/YY TO MM/DD/YY
B.PLACE OF SERVICE
C. EMG
D.PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circunstances)
CPT/HCPCS MODIFIER
E.DIAGNOSIS POINTER
F. $CHARGES
G.DAY OR UMITS
H.EPSOT FAMILY PLAN
I.
J.RENDERING PROVIDER ID#
block 25
FEDERAL TAX I.D. NUMBER SSN EIN
block 26
PATIENT ACCOUNT NO.
block 27
ACCEPT ASSIGMENT?
block 28
TOTAL CHARGE
block 29
AMOUNT PAID
block 30
BALANCE DUE
block 31
SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES CREDENTIALS (I CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOFF)
SIGNED_______ DATE_______
block 32
SERVICE FACILITY LOCATION INFORMATION
a.
b.
block 33
BILLING PROVIDER INFO & PH ( )
a.
b.
Billing Entity
Is the legal business name of the practice.
Diagnosis Pointer Number
1 through 4 are preprinted in Block 21 of the CMS-1500 claim, and they are reported in Block24E
Medically Unlikely Edits (MUE) Project
To imporve the accuracy of Medicare payments by detecting and denying unlikely Medicare claims on a prepayment basis.
Medigap
Plans, which are supplimental palns designed by the Federal Governenment, but sold by private commerical insurnace companies to “cover the gaps in Medicare”.
National Plan and Provider Enumeration System (NPPES)
Developed by CMS to assign the unique healtcare provider and health plan identifiers and to serve as a database from which to extract data (e.g., health plan verification of provider NPI).
Optical Character Reader (OCR)
A device used for optical character recognition.
Optical Scanning
Uses a device (scanner) to convert printed or handwritten characters into text that can be viewed by an optical character reader (OCR)
Observation Care
A well-defined set of specific, clinically appropriate services, which include ongoing short-term treatmnet, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
Direct Admission
Occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department. (ED)
Nonphysician Practitioner (NPP)
e.g., nurse practitioner, physician assistant
POS
Place of service on CMS-1500 (Appendix II)
HCFA stands for : – Health Care Financing Administration

The HCFA-1500 paper health insurance form was developed in______ by ________________ : – 1975; Health Care Financing Administration (HCFA)

The HCFA claim form was developed to be used by providers for what purpose? – Billing Medicare for outpatient services

HCFA changed its name to what in July of 2001? – Center for Medicare and Medicaid Services (CMS)

HCFA-1500 claim form was changed to this in July of 2001 : – CMS-1500 Universal Claim Form

For EVERY patient, the patient’s insurance company should be contacted to verify what? – 1) The patient’s eligibility
2) Coverage is in effect
3) Which benefit plan the patient has

The paper CMS-1500 claim form can be submitted via what means? – Mailed; or scanned & submitted

Medicare & Medicaid claim forms may be submitted electronically using the : – 837P standardized encrypted format

As of October 16, 2003, HIPAA required all claim forms to be submitted electronically with what exception? – Claims submitted to smaller companies

Verification of eligibility, coverage, and insurance plan helps the billing specialist with what? – 1) Faster processing of the patient’s services
2) Knowing which expenses the patient is responsible for
3) Assisting in patient education of insurance coverage

Electronic claims can be submitted in three ways. They are? – 1) Direct data entry
2) Dial-up telephone
3) Computer over the internet

What is Direct Data Entry? – Data is electronically transmitted from a provider’s computer system into a health insurer’s computer system.

What is a Clearinghouse? – A centralized, independent facility or entity that processes claims electronically to various insurance companies after receiving them from the provider.

What does a Clearinghouse do with the claims PRIOR to submitting them to the insurance companies? – They separate the claims by carrier, scrub the claim checking for errors, & submit clean claims to the appropriate insurance company for payment.

What does a Clearinghouse do with claims with missing or incorrect information? – Return it to the provider for correction.

Info found in TOP portion of the CMS-1500? – Patient related info such as their name, address, date of birth, marital status, gender, insurance info, & possibly employer info if work related.

Info found in BOTTOM half of the CMS-1500? – Provider’s service & billing info, incl diagnosis & procedure codes, hospitalization dates, NPI & Tax ID numbers, etc.

What’s a Signature on File (SOF)? – Signatures which have been obtained in advance from the provider on the contract with the third party, & from the patient for billing purposes retained in their medical records.

What does SOF stand for? – Signature on file

Where does SOF get entered for the provider? – Box 31

Where does SOF get entered for the patient? – Boxes 12 & 13

How long must signatures be kept on file AFTER a claim has been submitted? – 72 months

HOW OFTEN must a provider obtain the patient’s signature to be on file for their record? – Once a year

The NPI replaced what two previously used identifiers? – The PIN & the UPIN

What is the NPI used for? – To identify each health care provider & facility for all transactions & with all health plans.

This 10-digit ID number was required by HIPAA, & assigned by the CMS : – National Provider Identifier (NPI)

When does the NPI expire? – Never. It’s a lifelong number.

Numbers assigned by IRS to employers for purpose of income tax reporting, & also used on health claims : – EIN (Employer Identification Number )
or TIN (federal Tax Identification Number)

What does POS stand for? – Place of Service code

What is a POS code used for? – To identify where services were provided.

Where are POS codes located? – In front of CPT book

What’s an OCR scanner? – Optical Character Recognition scanner

NOTHING may be __________ to the CMS-1500 : – Stapled

ICR scanners are another method of scanning. ICR stands for : – Intelligent Character Recognition or Image Copy Recognition

Scanned CMS-1500 forms must be filled out using : – Black color, such as black typewriter ink or OCR printer ribbons

Scanned documents must NEVER be handwritten and all letters must be typed using : – UPPER CASE letters

It’s important to align the typewriter or printer so that : – Words & characters appear in proper fields, & DO NOT touch the lines.

Don’t use the terms NA or DNA. Do this instead : – Leave the box blank

NOT ONLY may you not strike over any errors, you also MAY NOT USE ____________ to cover errors : – Correction tape or fluid

Use of these types of pens ARE NOT allowed on CMS-1500 paper claim forms : – Highlighters or any other color except black

These types of print, fonts, etc. MAY NOT be used on CMS-1500 claim forms : – 1) Script
2) Italicized font
3) Expanded, compressed, bold, or proportional print

NOT ALLOWED on CMS-1500 claim forms, UNLESS instructed to do so : – 1) Symbols (such as #, – , /)
2) Period marks
3) Ditto marks
4) Parentheses
5) Commas

Use this format for the date : – MM-DD-YYYY

The ONE exception to usual format used for the date on the CMS-1500 is located where? – In Box 24A it may be listed as MM-DD-YY so it will fit in spaces provided.

Make sure all of the X’s are : – Completely inside their respective boxes.

Where the following symbols would normally be used, leave a blank space instead : – 1} $
2} –
3} ()

UNLESS they appear on the patient’s insurance card, never use these : – Titles such as Jr. & Sr.

Express whole dollars by using the following in the “cents” column : – Two zeros

ALWAYS submit the ORIGINAL CMS-1500 claim form, and NEVER these : – Photocopies

If amount received from primary insurance carrier IS NOT in whole dollar amounts, biller would : – Enter exact amount in Box 29 & adjust balance due in Box 30 before sending claim to secondary or tertiary insurance carrier.

When dealing with a pregnancy, Box 14 would be filled out using : – Date of patient’s last menstrual cycle.

If patient has had the same, or similar, illness in past; in Box 15, the biller would record : – The date when the patient had the same, or similar, illness the first time.

For each procedure, service, or supply the patient received in Box 24D, enter the corresponding diagnosis number from: – Box 21

If more than one number is needed in Box 24E, then list them in the following manner : – One after the other with NO PUNCTUATION between them.

A CLEAN claim has : – 1) No missing data or errors
2) Been filed timely
3) Passed all edits
4) No staples, No highlighted areas, bar code area not deformed
5) No additional work required by biller

A REJECTED claim : – 1) Cannot be processed due to technical errors, invalid, or missing info, claim submission instructions not being followed
2) Has been submitted to, & rejected by, 3rd party
3) A code is submitted showing reason for rejection
4) Must be corrected, then resubmitted, by Biller

A DENIED claim : – 1) Services not covered under policy
2) Ineligible service
3) Applied to the deductible
4) No coverage on date of service
5) NOT resubmitted, but forwarded to patient for payment

A DIRTY claim : – 1) Submitted with errors requiring manual processing
2) 3rd party insurance can either pend, or suspend, the claim
3) Could be rejected
4) Holds up payments
5) Biller may contact 3rd party to attempt to resolve errors & speed payment

A DINGY claim : – 1) Are the result of the Fiscal Intermediary (FI)
2) They are unable to process it due to system problem
3) Claims are put on hold until necessary changes made to system & claim can be processed.

An INCOMPLETE claim : – 1) Missing required information.
2) Claim is rejected by the 3rd party
3) Claim is corrected & resubmitted by Biller

An INVALID claim : – 1) Claim has illogical or incorrect information
2) Claim is rejected by 3rd party
3) Claim is corrected, & resubmitted, by Biller

Examples of illogical information found on an INVALID claim are things such as : – 1) Provider doesn’t match provider name
2) Patient’s sex doesn’t correlate with procedure
3) Date of birth doesn’t make sense for patient

A PENDING claim: – 1) 3rd party has suspended this claim for some reason requiring further investigation.
2) Sometimes requires additional info from patient.
3) These claims eventually may be paid or denied.
4) If staff obtains correct info, may be resubmitted for payment

Claim follow-up is very important because : – It leads to revenue, which leads to financial stability in the office.

HIAA – Health Insurance Association of America

AMA – American Medical Association

The form eventually became known as __________ or Attending Physician’s Statement – COMB-1

The AMA approved a “___________” called the Health Insurance Claim Form. – universal claim form

paper claim – is submitted on paper including optically scanned claims that are converted to electronic form by insurance companies.

An ___________ is one that is submitted to the insurance carrier via dial-up modem, direct data entry, or over the Internet by way of digital subscriber line (DSL) or file transfer protocol (FRP) – electronic claim

What are the three claim status? – 1) clean claim
2) rejected claim
3) pending claim

What are the four other claim status? – 1) incomplete claim
2) invaild claim
3) dirty claim
4) deleted claim

Abstraction of technical information from patient records may be requested for three situation: – 1) to complete insurance claim forms
2) when sending a letter to justify a health insurance claim after professional services are rendered
3) when a patient applies for life, mortgage, or health insurance

Physician services for inpatient care are billed on a fee-for-service basis, and physicians submit ___________ __________ service procedure codes. – CPT/HCPCS LEVEL II

A patient develops surgical complications and returns to the operating room to undergo surgery related to the original procedure. The return surgery is – IS BILLED AS AN ADDITIONAL SURGICAL PROCEDURE.

Outpatient surgery and surgeon charges for inpatient surgery are billed according to a global fee, which means that the pre-surgical evaluation and management, initial and subsequent hospital visits, surgical procedure, discharge visit, and uncomplicated postoperative follow-up care in the surgeons office are billed as ? – ONE CHARGE

When one charge covers pre-surgical evaluation and management, initial and subsequent hospital visits, surgical procedure, the discharge visit, and uncomplicated postoperative follow up care in the surgeons office, this is called a ? – GLOBAL FEE

A situation that requires the provider to write a letter explaining special circumstances ? – A PATIENTS INPATIENT STAY WAS PROLONGED BECAUSE OF MEDICAL OR PSYCHOLOGICAL COMPLICATIONS.

The optical character reader (OCR) is a device that is used to ? – VIEW CMS 1500 TEXT.

When entering patient claims data onto the CMS 1500 claim, enter alpha characters using ? – UPPER CASE.

An accurate interpretation of the phrase “assignment of benefits” on the CMS 1500 form with a signature of the patient means ? – THE PAYER IS INSTRUCTED TO REIMBURSE THE PROVIDER DIRECTLY.

When an X is entered in one or more of the YES boxes in Block 10 of the CMS-1500 claim, payment might be the responsibility of a ________ insurance company. – HOMEOWNERS

The billing entity, as reported in Block 33 of the CMS-1500 claim, includes the legal business name of the ? – MEDICAL PRACTICE.

When a patient is covered by a large Employer Group Health Plan (EGHP) and Medicare, which is primary? – THE EGHP – EMPLOYER GROUP HEALTH PLAN

When a child is covered by two or more plans, lives with his married parents, the primary policyholder is the parent ? – WHOSE BIRTHDAY OCCURS FIRST IN THE YEAR.

When an insurance company uses the patient’s social security number as the patient’s insurance identification number, Block 1a of the CMS 1500 claim ? – CONTAINS THE IDENTIFICATION NUMBER WITHOUT HYPHENS OR SPACES.

When the CMS 1500 claim requires spaces in the data entry of a date, the entry looks like? – MM DD YYYY OR MM DD YY.

When completing a CMS 1500 claim using computer software, test should be entered in? – UPPER CASE.

When the CMS 1500 claim requires a response to YES or NO entries, enter a ? – X

When SIGNATURE ON FILE is the appropriate entry for a CMS 1500 claim block, which is also acceptable as an entry? – SOF

Block 14 of the CMS 1500 claim requires entry of the date the patient first experienced signs or symptoms of an illness or injury. Upon completion of Jean Mandel’s claim, you notice that there is no documentation of that date in the record. The provider does document that her pain began five days ago, today is May 10th, YYYY, what do you enter in Block 14? – 05 05 YY

Blocks 24A – 24J of the CMS 1500 form contain shaded rows, which contain ? – SUPPLEMENTAL INFORMATION, PER PAYER INSTRUCTIONS.

Block 24A of the CMS 1500 claim contains dates of service (From and To). If a procedure was performed on May 10, YYYY, in the office, what is entered into the TO Block? – 05-10-YYYY

Nancy White’s employer provides individual and family group health plan coverage, and it pays 80 percent of her annual premium. Nancy selected family coverage for her group health plan, which means her employer pays $12,000 per year, (of the $15,000 annual premium). Nancy is responsible for the remaining $3,000 of the annual premium, which means that approximately ____ is deducted from each of her 25 biweekly paychecks. – $125

When Block 25 of the CMS 1500 claim form contains the providers EIN, enter ___ ___ ___ ___ after the first two digits of the EIN. – NO PUNCTUATION OR SPACE

When a patient is covered by the same primary and secondary commercial health plan how many claims do you submit to the payer? – SUBMIT JUST ONE CMS 1500 CLAIM TO THE PAYER.

When entering the patient’s name in Block 2 of the CMS 1500 claim, separate the last name, first name, and the middle initial (if known) with ? – COMMAS.

Block 33a of the CMS 1500 claim contains the providers? – NPI.

One of the requirements that a participating provider must comply with is to? – MAKE FEE ADJUSTMENTS FOR THE DIFFERENCE BETWEEN AMOUNTS CHARGED TO PATIENTS FOR SERVICES PROVIDED AND PAYER-APPROVED FEE’S.

Which is a program that requires providers to adhere to managed care provisions? – PREFERRED PROVIDER NETWORK.

One of the expectations that a non-participating provider has is to ____ ____ ____ ___ ___ ____ ____ for services rendered. – OBTAIN PAYMENT FOR THE FULL FEE CHARGED

Which is considered a minimum benefit under BCBS basic coverage? – HOSPITALIZATIONS.

Which is considered a service reimbursed by BCBS major medical coverage? – MENTAL HEALTH VISITS.

Which is a special clause in an insurance contract that stipulates additional coverage over and above the standard contract? – RIDER.

BCBS indemnity coverage is characterized by certain limitations, including ? – HOSPITAL-ONLY OR COMPREHENSIVE HOSPITAL AND MEDICAL COVERAGE.

Prospective authorization or prepcertification is a requirement of the _____ ______ ______ BCBS managed care plan. – OUTPATIENT PRETREATMENT AUTHORIZATION

Which phrase is located on a Federal Employee Program plan ID card? – GOVERNMENT-WIDE SERVICE BENEFIT PLAN.

The plan ID card for a subscriber who opts for BCBS’s Healthcare Anywhere PPO coverage uniquely contains the _____ logo. – SUITCASE

How many charactersin length are the HCPCS Level II national codes? – 5

Are they alpha, numbric, or alphanumeric? – Alphanumeric

What was the reason that the change was made from using retrospective payment systems to prospective payment systems? – To reduce costs

With the retrospective reasonable cost system, what was submitted for charges? – The actual charges for inpatient care.

What are some examples of the different prospective payment systems? – 1. Ambulance fee schedule 2. Ambulatory Surgical Center payment rates 3. Clinical Laboratory Fee Schedule 4. Durable Medical Equipment 5. Prosthetics, Orthotics, and Suplies Fee Schedule 6. End-stage Renal Disease Composite Payment Rate System, 7. Hospital Inpatient PPS, 8. Skilled Psychiatric Facility PPS 9. Skilled Nursing Facility

What are the biggest differences between cost and price based systems? – Cost-based is based on case mix (acuity) and Price-based is based on category of patients.

Which systems should be classified as price based but, as exceptions, are cost based. – Walking psycho SNFRS. (Walking) = Ambulatory surgery; (Psycho) = Inpatient Psychiatry; (SNFRS) = Skilled Nursings Facilities

What is a fee schedule? – A list of pre-determined payments for health care services provided to patients.

What are some incentives mandated by congress to increase the number of PARS? – 1. Direct payment of all claims.
2. 5% higher fee schedule
3. Published in the PARS directory

What is meant by case mix? – A measure of the types and categories of patients treated by a healthcare facility or provider. It reflects patient utilization of varying levels of healthcare resources (acuity).

The billing entity, as reported in Block 33 of the CMS-1500 claim, includes the legal business name of what? – The medical practice. The billing entity.
Means the same thing.

What case is required for entering data onto the CMS-1500 claims? – Uppercase

What is a combined medical-surgical case? – The patient is admitted to the hospital as a medical case but, after testing, requires surgery.

How is a date of birth entered on a claim? – MM DD YYYY

How many hours are allowed for observation hours? – 48

Are observation hours inpatient or outpatient? – Outpatient

What is OCR? – Optical Character Reader

Why would you need to include attachments for claims? – 1. Surgery defined as an inpatient procedure that is performed at an ASC or office.
2. Surgery typically characterized as an office or OP procedure that is performed in an ASC or as a hospital inpatient.
3. A patient’s stay in the hospital prolonged due to medical or psychological complications.
4. An OP or office procedure is performed as an IP procedure because of high-risk case.
5. Why a fee is higher than normal for coded procedure.
6. “Unlisted procedure” CPT code number.

Where do you enter ICD-9-CM codes on the claim? – 21

How many diagnosis codes can you enter on a claim form? – 4

What does the “Signature on file” (or SOF) in block 13 mean? – Authorizes direct payment to provider for benefits. The patient has previously signed an authorization to release medical info to the payer, and it is maintained “on file” by the provider.

Why was the decision to use one claim for multiple insurance types made? – Uniformity, efficiency. Each payer used to have their own form, causing much confusion.

How many procedures are permitted on a claim? – 6

Why would you check periodically with all payers regarding claim completion? – Commercial payers implement changes to claims completion requirements.

is there a date required in Block 12? – NO

What characters are used in a Medicare number? – A social security number with a letter at the end.

Who is eligible for Medicare? – 1. Individuals/spouses that have worked in a medicare-covered employent for at least 10 years.
2. Individuals 65 years & older.
3. Must be citizens or permanent residence of US.
4. End-stage renal failure at any age.

What Medicare plan is for inpatients? – Medicare Part A

What Medicare plan is for prescription coverage? – Part D

How many days are given for “lifetime reserve days”? – 60

After what amount of time does a patient’s benefit period end? – 60 consecutive days with not visits or anything.

What information is protected by the Federal Privacy Act of 1974? – Patient, Date of Service, Paid Amount

What is the purpose of PACE? – to help the person maintain independence, dignity and quality of life.

What is the form used to notify Medicare patients that their procedure or service may not be covered by Medicare? – ABN = Advance Beneficiary Notice

Who provides financial backing for Medicaid? – The states and Federal governments

What is the previous name for Temporary Assistance to Needy Families (TANF)? – Aid to families with Dependent Children (AFDC) Program

What is the purpose of TANF? – Makes cash assistance available on a time-limited basis for children deprived of support because of a parent’s absence, death, incapacitated or unemployment.

What is meant by dual eligibles? – An individual is entitled to Medicare and eligible for some type of Medicaid benefit. (Medi-Medi) Medicaid is always the payor of last resort.

What is the Federal Medical Assistance Percentage? – The portion of the medicaid program paid by the federal government.

Children under what age are included as medically needy eligible? – 18 or 21, depending upon whether or not they are in school.

When a patient has Medicaid coverage as well as another, Medicaid is considered: – Medicaid is always considered the secondary or payor of last resort.

What percentage of payment does a provider consider Medicaid payments? – 100%

What is the old name of TRICARE? – CHAMPUS

Who is eligible for CHAMPVA? – Veterans of the armed services, their survivors/dependents

What are the features offered by TRICARE Prime? – 1. Guaranteed access to timely medical care.
2. Priority for care at Military treatment facilities.
3. Assignment of a primary care manager.
4. Lowest cost option of the three TRICARE options.
5. Requires enrollment for one year.
6. Retired military pay on annual enrollment fee.
7. Care sought outside of TRICARE Prime Network is costly.
8. May be unavailable in some TRICARE regions.

What are the features offered by TRICARE Extra? – 1. Choice of any physician in the network.
2. Less costly than TRICARE Standard.
3. Maybe more expensive than TRICARE Prime.
4. Annual enrollment is not required.
5. Lower priority for care provided at MTFs.

Who is eligible for TRICARE Prime? – 1. Active duty military personnel
2. Family members of active-duty sponsers (no enrollment fee).
3. Retirees and their family members all of whom, are under the age of 65.

Is CHAMPVA primary or secondary to Medicare? – Secondary

How many regions are there for TRICARE? – 4

How do you verify TRICARE coverage? – Use the DEERS program. DEERS = Defense Enrollment Eligibility Reporting System.

Who has to enroll in DEERS? – All sponsers enroll annually.

What is the name of a sequence of activities that can normally be expected to result in the most cost effective clinical course of treatment? – Critical pathway

What form is required to be completed at the time an employee is injured? – First Report of Injury

Who is eligible for workers’ compensation benefits? – Employee must be either injured while working within the scope of the job description, injured while performing a service required by the employer, or develops a disorder that can be directly linked to employment. Stress related disorders.

How frequently do WC recipients receive wage benefits? – Weekly

Who is eligible for federal workers’ compensation plans? – Coal miners, longshoremen, harbor workers, and all federal employees with work related injuries. Not military.

What does the Office of Workers’ Compensation Programs (OWCP) provide? – Wage replacement, benefits, medical treatment, vocational rehabilitation.

Who is responsible for administrating WC laws? – The US Department of Labors Office of Workers’ Compensation Program, Workers’ Compensation Board.

What requires employers to maintain WC coverage for work-related injuries and illnesses? – Federal and State Laws

Do all providers need to accept WC payment as full payment? – Yes. No balance billing is allowed.

Billing Entry – …

Diagnosis Pointer Number – …

Medically Unlikely Edits (MUE) Project – …

Medigap – …

National Plan and Provider Enumeration System (NPPES) – Developed by CMS to assign the unique healtcare provider and health plan identifiers and to serve as a database from which to extract data (e.g., health plan verification of provider NPI).

Optical Character Reader (OCR) – A device used for optical character recognition.

Optical Scanning – Uses a device (scanner) to convert printed or handwritten characters into text that can be viewed by an optical character reader (OCR)

Supplemental Plan – …

Observation Care – A well-defined set of specific, clinically appropriate services, which include ongoing short-term treatmnet, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Direct Admission – Occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department. (ED)

Nonphysician Practitioner (NPP) – e.g., nurse practitioner, physician assistant

POS – Place of service on CMS-1500 (Appendix II)

CMS Form 1500 (08/05)
A. Both C & E
B. Invalid form
C. Ambulance Form
D. Electronic Claim
E. Standard Form
F. Beneficiary Form E. Standard Form

ASC X12N 837
A. Both C & E
B. Invalid form
C. Ambulance Form
D. Electronic Claim
E. Standard Form
F. Beneficiary Form D. Electronic Claim

CMS Form 1490S
A. Both C & E
B. Invalid form
C. Ambulance Form
D. Electronic Claim
E. Standard Form
F. Beneficiary Form B. Invalid form

CMS Form 1492
A. Both C & E
B. Invalid form
C. Ambulance Form
D. Electronic Claim
E. Standard Form
F. Beneficiary Form C. Ambulance Form

The term used for Medicare’s editing process, which returns claims with incomplete or invalid information is:
A. Medicare as a Secondary Payer
B. Crossover
C. Unprocessable Claims
D. Assigned Claims C. Unprocessable Claims

If your claim had a service date of October 1, 2008, then what would the filing time limit be for filing your claim?
A. December 31, 2008
B. December 31, 2009
C. December 31, 2010
D. December 31, 2011 A. December 31, 2008

Providers are required to file claims on behalf of the beneficiary, but can the provider charge them a fee for completing and filing the claim? yes

In what block of the CMS 1500 (08/05) claim form should the patient’s Medicare number be entered?
A. Block 1
B. Block 1a
C. Block 2
D. Block 4 D. Block 4

How do you indicate the patient’s signature on the CMS 1500 (08/05) claim form?
A. SOF in block 12
B. Have the patient sign block 12
C. Signature on file in block 12
D. Any of the Above D. Any of the Above

Medicare is the secondary payer to TRICARE and Medicaid. false

Question 8
If your patient had a fall in a store and dislocated his/her hip, where would you indicate this potential liability situation on a claim form?
A. Block 9
B. Block 10b
C. Block 10c
D. Block 11 C. Block 10c

Can you file Medicare Secondary Payer claims electronically? yes

If a claim is denied in full, Medicare will never cross the claim over to Medicaid. false

If you are a physician in a solo practice, in what block of the CMS 1500 (08/05) claim form would you enter your provider name, number, phone number, and complete address?
A. Block 17a
B. Block 24j
C. Block 33
D. None of the above C. Block 33

Should the provider code the patient’s diagnosis to the highest level of specificity? yes

How would the provider indicate in block 24e (diagnosis pointer) what diagnosis applies to each procedure?
A. Use multiple indicators from block 21
B. Enter diagnosis from block 21
C. Enter multiple diagnoses from block 21
D. Use only one of the 1-4 indicators from block 21 D. Use only one of the 1-4 indicators from block 21

Can a provider group non-consecutive dates of service in block 24a for subsequent hospital visits? yes

The editing process will return claims to you if they are incomplete or contain incorrect information. true

You have appeal rights if your claim has been returned to you due to criteria determined by the “unprocessable claims” editing process. false

If your claim had a service date of October 1, 2005 what would be the time limit for filing your claim?
A. December 31, 2004
B. December 31, 2005
C. December 31, 2006
D. December 31, 2007 D. December 31, 2007

What is the penalty for filing an assigned claim after the filing time limit?
A. 25% B. 75%
C. 15% D. 10% D. 10%

What is the penalty for filing a non-assigned claim after the deadline?
A. Up to $2,000
B. Up to $3,000
C. Up to $4,000
D. Up to $5,000 A. Up to $2,000

Providers file claims on behalf of beneficiaries, but can providers charge beneficiaries a fee for filing the claim? no

In what block of the claim form is the patient’s Medicare number entered?
A. Block 1
B. Block 1a
C. Block 2
D. Block 3 B. Block 1a

How would you indicate the patient’s signature on a claim form?
A. SOF in block 12
B. Have the patient sign and date block 12
C. SIGNATURE ON FILE in block 12
D. Any of the above D. Any of the above

Can you file Medicare Secondary Payer claims electronically? yes

What information is required for Medigap crossovers?
A. Payer ID # (OCNA or N-key ID, which will be Carrier/MAC assigned) in block 9d (or Medigap insurance plan name)
B. Insured’s name or “same” in 9
C. The word MEDIGAP (or MG or MGAP) and policy # and/or group number of the insured in 9A
D. Insurer address in 9c (unless PayerID is in 9d)
E. Patient signature (or signature on file SOF) in blocks 12 and 13
F. Insured’s date of birth and sex in 9b
G. All of the above G. All of the above

What kind of number is required in block 17b for the following services if they are the result of a physician’s referral: e.g., diagnostic lab, diagnostic radiology, consultations, DME, parenteral and enteral nutrition, and immunosuppressive drugs? NPI

If you are billing for:
Routine Foot Care
Chiropractor services
Not Otherwise Classified drugs
Unlisted Procedures
More than 2 modifiers
Independent Lab and homebound patients
Patient refuses to assign benefits
Hearing Aids
Dental Exams
Low Osmolar Contrast Material
Split Care
In what block of the CMS Form 1500 (08/05) would you enter additional narrative information? block 19

How would you indicate in block 24e (diagnosis pointer) what diagnosis applies to each procedure?
A. Use multiple indicators from block 21
B. Enter diagnosis from block 21
C. Enter multiple diagnoses from block 21
D. Use only a single indicator (1, 2, 3, or 4) from block 21 D. Use only a single indicator (1, 2, 3, or 4) from block 21

Should the provider code the patient’s diagnosis to the highest level of specificity? yes

If a single service, let’s say an office visit, is performed, then what must be entered in block 24g (quantity billed)? 1

Which form is also known as the “standard and Ambulance Form”?
A. CMS-1500(08/05)
B. ASC X12N 837
C. CMS-1450S
D. HIPAA A. CMS-1500(08/05)

What is the term used for Medicare’s editing process, which returns claims with incomplete or invalid information?
A. Beneficiary Compensation
B. Unprocessable Claims
C. Secondary Payer
D. Multiple Indicators B. Unprocessable Claims

If your claim had a service date of 10-1-2008, then what would be the filing time limit for filing your claim?
A. 12-31-2008
B. 12-31-2009
C. 12-31-2010
D. 12-31-2011 C. 12-31-2010

A provider can charge a beneficiary a fee for completing and filing a claim. false

Block 1a of the CMS 1500 (08/05) claim form should contain the patient’s:
A. Name
B. Medicare number
C. Signature
D. Address B. Medicare number

How do you indicate the patient’s signature on the CMS 1500 (08/05) claim form?
A. SOF in block 12
B. Have the patient sign block 12
C. Signature on file in block 12
D. Any of the Above D. Any of the Above

Can Medicare be the secondary payer for TRICARE and Medicaid? no

If your patient fell down a flight of stairs in a commercial building and broke an arm, where would you indicate this potential liability situation on a claim form?
A. Block 9
B. Block 10b
C. Block 10c
D. Block 11 C. Block 10c

Can you file Medicare Secondary Payer claims electronically? yes

If a claim is denied in full, Medicare will never cross the claim over to Medicaid. false

If you are a physician in a solo practice, in what block of the CMS 1500 (08/05) claim form would you enter your provider name, NPI number, phone number, and complete address?
A. Block 14
B. Block 20
C. Block 33
D. None of the Above C. Block 33

Should the provider code the patient’s diagnosis to the highest level of specificity? yes

How would the provider indicate in block 24e (diagnosis pointer) what diagnosis applies to each procedure?
A. Use multiple indicators from block 21
B. Enter diagnosis from block 21
C. Enter multiple diagnoses from block 21
D. Use only one of the 1-4 indicators from block 21 D. Use only one of the 1-4 indicators from block 21

Can a provider group non-consecutive dates of service in block 24a for subsequent hospital visits? no

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