Medicaid

Front 1

adjusted claim

Back 1

payment correction resulting in additional payment to the provider;amount over or underpaid

Front 2

dual eligibility

Back 2

eligible for both Medicare & Medicaid

Front 3

EPSDT

Back 3

Early & Periodic screening Diagnostic & treatment

Front 4

Federal eligibility requirement for medicaid

Back 4

-families who meet TANK req.
-ppl with SSL
-infants born to medicaid-eligible women
-kids under 6 w/family income 133% below PL
-recipients of adoption assistance & foster care

Front 5

FMAP

Back 5

Federal Medical Assistance Percentage

Front 6

Mandatory services under Medicaid

Back 6

-inpatient -nursing facility
-outpatient -prenatal care
-x-ray & labs
-family family

Front 7

medicaid coverage categories

Back 7

mandatory, optional & preauthorize

Front 8

medically needy

Back 8

individuals who have too much income to qualify under mandatory or optional groups

Front 9

monthly survey letter

Back 9

checks to see if services were actually performed

Front 10

mother-baby claims

Back 10

services for babies are filed under the mothers identification #

Front 11

optional services under medicaid

Back 11

-optometrist
-dental services
-prosthetic services
-transportation services
PACE- programs of all-inclusive care for the Elderly

Front 12

payer of last resort

Back 12

always secondary insurance, unless it is the persons only insurance

Front 13

presumptive eligibility

Back 13

offers temporary coverage while medical application is pending

Front 14

QDWI

Back 14

Qualified Working Disabled Individual. Pays part of A premiums for those who lose coverage due to work or income @ or below 200% of poverty

Front 15

QMB

Back 15

Qualified Medicare Beneficiaries= pay for individuals w/income at below or below 200% of PL

Front 16

Remittance Advice

Back 16

shows current status of all claims- paid, adjusted & voided claims

Front 17

SCHIP

Back 17

state children s health insurance program

Front 18

SLMB

Back 18

Specified low income Medicare Beneficiaries- pay part of B premium for those w/ income 100-120 % of PL

Front 19

SSI

Back 19

Supplemental security income

Front 20

subrogation

Back 20

the assumption of an obligation for which another party is primarily liable

Front 21

TANF & what do they do?

Back 21

temporary assistance for needy families; cash assistance for limited time for for kids deprived of support. parents death or absence

Front 22

Voided Claim

Back 22

claim that medicaid should not have paid, resulting in deduction from payment made from provider

Front 23

SURS & what does it do?

Back 23

Surveillance & Utilization Review System; identifies fraud & abuse

Front 24

PACE

Back 24

Programs of All-inclusive Care to the Elderly

Front 25

Participating providers

Back 25

must accept payment in full

Front 26

MEVS

Back 26

Medicaid Eligibility Verification System, allows provider to electronically access states eligibility file

Front 27

FMAP

Back 27

Federal medical Assistance Percentage;
portion paid by federal gov't; determined annually for each sate using formula that compares states avg. per capita income w/ national avg.; wealthier states get smaller reimbursement

Front 28

medicaid originally administered by ?

Back 28

SRS- Social Rehab Services

Front 29

6 mandatory services

Back 29

-inpatient services -nursing facility
-outpatient - x-ray & lab
-prenatal care
-family planning

Front 30

4 preauthorized services

Back 30

1. elective inpatient
2. emergency inpatient
3. outpatient procedure performed inpatient setting
4.days exceeding state hospital stay laws

Front 31

when is patient billed for service?

Back 31

any service that is a non-covered benefit

Front 32

3 ways to verify Medicaid Recipient

Back 32

1. point of sale device (POS)-credit card -like swipe card
2.website
3.automated voice response system

Front 33

5 things needed to meet medicaid elgibility

Back 33

1. preggo women & unborn child
2. kids up 18 or 21 depending on state
3.65 or older, blind, disabled ppl /low income & resources
4.ppl elgible for medicare w/low income & limited resources
5. other: ineligible for welfare but need health care coverage

Front 34

3 federally mandated eligible groups

Back 34

1. optional categorically related groups
2. disabled medicaid beneficiaries who work
3. SCHIP

Front 35

what is a mandatory categorically group?

Back 35

-SSI recipients [supplemental security income]
-kids 6 & under
-preggo women w/ income @ or below 133% FPL
-adoption assistance & foster care
-limited income families w/,kids that meet TANF

Front 36

who is covered under Optional Medicaid eligibility group?

Back 36

1.institutionalized ppl w/limited income & resources
2.would eligible if institutionalized but receiving care thru home & community-based services waivers
3.TB infected
4kids under 21 meet income & resource reQ. for TANF but otherwise not eligible for TANF.
5.optional targeted low-income kids
6.certain aged, blind or disabled adults- incomes above those requiring mandatory coverage but below FPL

Front 37

what is medically needy?

Back 37

meet medicaid requirements but income is above PL made by the state

Front 38

what is spend down

Back 38

dont have huge income but above FPL.. based on income pay out-of-pocket before medicaid kicks in.
on month to month basis. amount of coverage provided depends on income that month

Front 39

what is adjusted claims & voided claims?

Back 39

adjusted claims make payment correction ; overpaid or underpaid
voided claims means medicaid should have never paid

Front 40

how does medicaid check w/recipients that services were really provided

Back 40

monthly service letter

Front 41

if under dual coverage which deadline do you follow?

Back 41

Medicaid's deadline

Front 42

mother-baby claims is enabled when?

Back 42

first 10 days baby is under moms identification #

Front 43

presumption eligibility

Back 43

based on you word; eligibility not yet checked

Front 44

Spousal improvement Protection

Back 44

if married, spouse in hospital or nursing facility & qualify for medicaid coverage dont have to sell assets

Front 45

what is a "community spouse"

Back 45

spouse at home

Front 46

utilization review

Back 46

federal gov't requires states to verify medicaid services

Front 47

info that comes back w/claim

Back 47

readmittence advice

Front 48

medical necessity

Back 48

services only payable when service :
-consistent w/diagnosis & condition
-provided in response to life-threatening condition

Front 49

"spend down" part of what program?

Back 49

medically needy

Front 50

what is spend down?

Back 50

pay for medical expenses to lower income so yo meet income reQ.

Front 51

types of Special Groups?

Back 51

1.QBM= qualified medicare bene's
2.QWDI- qualified working disabled individuals
3.SLMB- specified low-income bene.
4. Qualifying individual- states pay Medicare Part B premiums for ppl w/ 120 - 135% incomes below FPL

Front 52

what kind of program is medicaid

Back 52

vendor payment

Front 53

after confirming MEVS? eligibility the provider receives?

Back 53

receipt ticket