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27 Cards in this Set
- Front
- Back
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What is medicare |
A benefit plan for the aged disabled or people with end stage renal disease |
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What is medicare eligibility based on |
Based on age, based on disability ,and based on end stage renal disease |
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What is medicare part a, part b, part C, and part D? |
Part a is hospital part B is outpatient provider services part C is medicare advantage part D is prescription drugs |
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Understand what circumstances may a patient submit their own claim to medicare |
It the patient has other insurance which should pay as primary patient may submit a claim and attach copy of the other Carrier EOB. If services are not covered by medicare but patient wishes for a formal coverage determination for their record patient may submit claim. If the provider refuses to submit the claim |
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Know the steps in the medicare appeal process |
Re determination, reconsideration hearing by an administrative law judge, review by the medicare appeal counsel, Judicial review |
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What is medicare's severity diagnosis related group billing MS-DRG |
Payments for inpatient hospital claims instead of the hospital itemize billing system a flat payment is made based on complications or comorbidities or major CCs that the patient may be experiencing along with principal diagnosis |
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What are medical or supplements what is the common name for the supplement |
Medigap The supplements are separate plans written exclusively for medicare participants that pay amounts that medicare don't pay |
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Know some of the covered services of medicaid |
Inpatient hospital care, outpatient hospital services, provider services, lab and X-ray service, screening diagnosis service, treatment of kids under 21 |
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How soon must medicaid bills be submitted |
With in 60 days of the end of the month for which services are rendered |
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Know the expectations to the medicaid billing time limit |
Dental bills, obstetric care, treatment plan completion, when the patient has other insurance coverage, retroactive eligibility, and with in one year of service |
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What is TAR and what is the used for |
Treatment authorisation form To obtain authorization for specific services |
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Who are the primary recipients of medicaid |
Categorically needy and medical needy |
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Know what medicaid programs are primary payers |
Vocational rehabilitation Services Blind Division of health services for the BlindMaternal and child health delivery funds Maternal and child health delivery funds |
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What is workers compensation |
A form of insurance that provides wage replacement and medical benefits on employees who are injured in the course of employment in exchange for the employee's right to Sue his or her employer |
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Know some of the benefits of workers compensation |
Non disability, temporary disability, permanent disability, death benefits rehabilitation benefits |
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Know some of the examples of fraud or abuse of workers compensation system |
I'm injured worker who cannot clearly describe the pain or injury or description changes An injured worker who delays reporting of injury |
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What are non disability claims |
Minor injuries that will not prevent a worker from doing their job |
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What are temporary disability claims |
Not able to perform their job requirement until they recover from injury or illness |
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What are permanent disability |
Begins after temporary disability when it is determined that the worker will not be able to return to work |
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What our death benefit |
When employee days at work compensate the family of a deceased injured worker for loss of income |
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What are rehabilitation benefits |
School or training Retrain injured worker in a physical ability that will help to seek future employment |
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What does perminent and stationary mean |
Nothing more can be done and patient will have the disability for the rest of his or her life |
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What is a medical service order |
A form that States that the patient is being referred to provider in regards to a work related injury and employer is responsible for coverage of services |
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What is a doctor's 1st report of injury illness form used for |
So the doctor can verify and actively describe injury |
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Know some of the guidelines to follow when building workers compensation claims |
They go in a separate file from any medical files Services rendered in a workers comp case our responsibility of the employer not injured worker Document all communications And use proper codes |
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What does the term adjudication mean |
Final judgment Patients released to work all benefits paid case closed |
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Does California love require employers to have workers compensation coverage |
Yes |
