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Level 1 of ERA
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CRCR
CRCR study
| Question | Answer |
|---|---|
| ERA | Electronic Remittance Advice |
| Level 1 of ERA | Receipt of Data/the information is printed |
| Level 2 of ERA | Electronic remittance is received, entered into computer, and viewed at terminal |
| Level 3 of ERA | Electronic remittance is received, entered into computer - remittance data are electronically posted by the patient accounting software, updating the patients account. |
| Level 4 of ERA | Total automation receipt, data entry, payment posting, adjustment processing |
| EFT | is the electronic transfer of funds from payer to payee thru the banking system (fasted way to move money) |
| SNF Services Covered (6) | Room and board, PT, OT, ST, Respiratory Carem Drugs, Blood transfusions, supplies and equipment |
| EDI | Electronic Data interchange |
| EDI used for? | translating, standardizing and sending transactions electronically (claims) 837. 270/271, etc... |
| 835 | Remittance |
| Violation of the DRG Window (3 day) causes | delay in billing, rejection of claim, additionaly sanctions, fines, revocation of medicare status |
| UBO4 is used for institutional providers(List 4) | hospitals, hospice, rural health clinic, snf |
| SNF IP rules | must be IP atleast 3 days before discharging to SNF, must be admitted with in30 days of IP stay. |
| DRG used for | Inpatient billing |
| APC used for | outpatient billing |
| Benefit SNF Period? | 100 Days during a benefit period/ Benefit period ends during which the patient is not a IP or SNF for 60 days. |
| CCI Edits are? | Program consists of Edits implemented w/claim processing to catch errors before sending out |
| Package Pricing is? | payment system in which a lump sum or bundled payment is negotiated between payor and some or all providers. |
| Site of service limitation? | health plans developed care plans for common disease and procedures and must happen in approved setting |
| Title 804 | governs actions of skip tracing |
| Title 805 | Collector communication ceasing communication |
| Title 806 | proibits harassment abuse from the collector |
| Title 807 | deceptive or false representations |
| Title 604 (FCRA) | gives permision to see credit reports by court, by consumer, and a reporting agency who has legitimate business to view |
| Hospice Benefits with Medicare include | 2 90 day periods and unlimited subsequent periods-60 days each |
| CMS 1500 is used by non institutional providers such as | physicians, allied health professions, CRNA, home health agency's and Medical Equipment suppliers |
| What is EFT balancing and Control | Use of EFT greatly simplifies cash balancing and control requirements. The bank notifies the provider of amount received and issues deposit. The provider balances this to the ERA received. |
| Common Provision found in manage care contracts for protection for medical expense that exceed certain levels. | STOP LOSS Protection |
| Per Diem payment | fixed daily payments that do not vary based on level of services/IP |
| Percentage Discount is | where the provider accepts a percentage discount from total charges. |
| Most common contracted payment models (7) | Percentage discount, DRG, APC, Case Rate, Per Diem, Package Pricing, Capitation |
| Method of payment to healthcare providers whereby a FIXED amount is paid per ENROLLEE to cover defined set of services over a specifica period of time | Capitation |
| The difference between providers charges and the insuracne payment that are written off the patients account as... | Contractual allowance |
| The first critical step for all patients arriving for service scheduled or unscheduled is verifying patients identity with 2 forms...list | ID, name, DOB, SSN |
| Time of Service Denials include | new technology used without determining coverage(3D), charges bundled/unbundled incorrectly, accuity level changes but pt type does not change, admission notification not done, Pt IP but should be OBs, test performed not ordered, invalid HPCPS coding |
| Post Service Denials include | late charges, 2 claims with DOS that overlap, untimely filing |
| Pre Service Denials include | No Pre Auth, clinicals not called for certification, INS not verified, Inaccurate Data entry, Copying registration without verifying |
| CLIA | Clinical Laboratory Improvemen Act |
| APC only covered under medicare part | B |
| Impacts of Denials besides loss of reimbursement and additional cost | Productivity(staff reworks files), patient loss of confidence, employee frustration increased(morals affected) |
| Onsite self pay is enhanced by the ability to accept these forms of payment | Cash, Credit, check or debit cards |
| Liability payers include | Auto, Work Comp, Premises for medical coverage under property cases |
| Healthplan process claim from reimbursement and subsequently pursues payment from liability payer is... | SUBORGATION |
| Medicare allows providers to submit liability claims after this waiting period | 120 days. |
| Claim against personal property that secures payment of a debt | Lien |
| CWF | Common Working File |
| Medicare has 2 types of appeals to charges | Beneficiary appeal and Provdier appeal |
| Second Placement accounts are | an agency accepting assignment of returned or cancelled debts from initial collection agency. |
| Title VI is called | Fair Credit Reporting Act |
| The truth and lending act is | Title I- established rules for consumers credit and sales and loans |
| Medicare will try to collect self pay portions for how many days? | 120 days then goes to collections agency |
| For an acount to be considered bad debt collection must have been attempted and documented T/F | True |
| Payment floors for IP claims | 13 days electronic/26 for paper claims |
| MR | Medical Record |
| MPI | Master Patient Index |
| CPI | Corporate Patient Index |
| Critical patient information collected when scheduling are used as identifiers(list 4) | Legal name, DOB, sex, SSN |
| DME examples | Wheelchairs, hospital beds, oxygen tanks |
| Homebound patients requiring periodic skilled nursing and therapeutic care ordered by physician | Home Health Care |
| Patients with incurable disease and have a life expectency of six months or less | Hospice Care |
| Orthopedic surgical patient that require intense PT/stroke PT who require comprehensive Rehab | Skilled Nursing Patients |
| Can you use a ABN for a IP stay | NO |
| When is a ABN required | when a test or service does not meet medical necessity according to LCD/NCD |
| Credit balances are created by | posting errors, billing errors, payment errors, hospital and payer system limitations |
| Chargemaster issues can result in | inappropriate reimbursement |
| Claim rejection is a claim rejected for a # of reasons (list some) | inability to identify patient, ineligibility of pt, noncompliance of the provider with billing requirements. |
| Medicare Claims must be filed within what qualifying time limit? | 1 year |
| Types of unscheduled patients (6) | Emergency, urgent inpatients, routine walkins outpatients, ED outpatients, obs patients, Newborn |
| 3 types of schedule patients | Scheduled IP, Scheduled OP, reaccuring/series |
| Enrollment and disenrollment of a healthplan transanction set | 834 |
| What must appear on the ABN? (5 items) | Service physician ordered, cost, date of service, non coverage reason, financial responsibility |
| Capitation Contract Payment Method is | provider received a flat fee every month for taking care of individual |
| Case Rate Contract Patyment Method is | specific condition forms the basis for establishing a single payment for all services(colonscopy) |
| Financial counseling payment options | Full payment proir to service, short term payment plan, bank loan |
| Underpayment denial | payer does not pay the agreed contract(Aetna) amount to provider(LUH) |
| Technical Denial | Demographic error, imcomplete insurance 411, no precert or auth, no contunied stay auth, exceeds frequency limit(pt visits) |
| Clinical Denial | not medically necessary, diagnosis and cpt do not match, carve out days, inappropriate level of care, HCPCS incorrect for procedure |
| Bankruptcy Chapter 7 | Straight- involuntary or voluntary |
| Chapter 11 | debtor reogranization (court supervised plan) within 120 days |
| Chapter 13 | Rehabilitation- does not liquidate-looks for future earnings |
| By siging a contractual agreement(aetna, cigna etc) the facility becomes | In network |
| Rural Hospitals with fewer than BLANK beds can be reimbursed by Medicare | 100 (often use of swing beds) |
| Patient discharged status code | 03 |
| 837 transaction set | coordination of benefits |
| 835 transaction set | claim payment/remittance advice |
| 277/278 transaction set | referral certification and authorization |
| 820 transaction set | healthplan premium payments |
Created by:
Copa
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