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Exam - Ch. 9-12

HIT Classification and Reimbursement

Question	Answer
Medicare Part A covers	hospital services.
The Original Medicare Plan requires a premium, a deductible, and	coinsurance.
Determine which of the following individuals is not eligible for coverage under Medicare without paying a premium.	a seventy-year-old man who has paid FICA taxes for twenty calendar quarters
Which modifier indicates that a signed ABN is on file?	GA
Under Medicare’s global surgical package regulations, a physician may bill separately for	diagnostic tests required to determine the need for surgery.
On claims, CMS will not accept signatures that	use signature stamps.
Under Medicare Advantage, a PPO __________ an HMO.	is less restrictive than
Under the Medicare Part B traditional fee-for-service plan, Medicare pays __________ percent of the allowed charges.	80
Medicare Part D covers	prescription drugs.
Medicare medical review is conducted by	the MAC.
___________ adults may be eligible for Medicare benefits.	Disabled
Medicare benefits are available to individuals in how many beneficiary categories?	six
Which part of Medicare was originally called Medicare + Choice?	Medicare Part C
Which Medicare Part provides coverage for durable medical equipment?	Medicare Part B
Medicare Advantage is under which part of Medicare?	Medicare Part C
Care in a skilled nursing facility is covered under	Medicare Part A
Outpatient hospital benefits are provided under	Medicare Part B
The coinsurance for Medicare Part B is	20 percent.
What is the legislation that redesigned the Medicare Part B reimbursement incentive and mandated the transition to the Medicare Beneficiary Identifier?	MACRA
The deductible for Medicare Part B is	set each year.
What is performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease?	screening service
How many CMS regional offices are there?	ten
All of the following are noncovered items under Medicare except	ultrasound screening for abdominal aortic aneurysms.
Which of the following is excluded under Medicare?	routine medical appliances
The Medicare program	employs MACs to pay the claims submitted by providers
Each Medicare enrollee receives a __________ issued by CMS.	Medicare card
Which of the following statements is true?	PAR providers can bill both Medicare and non-Medicare patients for missed appointments.
NCD is the abbreviation for	National coverage determination.
Medicare Physician Fee Schedule amounts are __________ higher than for nonparticipating providers.	5%
The modifier GZ is appended to procedure codes for noncovered Medicare services when	the item is expected to be denied as not reasonable but there is no signed ABN.
What is the collection of online articles that explain all Medicare topics?	Medicare Learning Network (MLN) Matters
HPSA is the abbreviation for	Health Professional Shortage Area.
The Medicare limiting charge is the __________ fee that can be charged for a procedure by a nonparticipating provider.	highest
The limiting charge under the Medicare program can be billed by	nonparticipating providers only.
What is the percentage of beneficiaries who are in the Original Medicare Plan?	30%
Medicare beneficiaries receive a(n) __________, which is an explanation of Medicare benefits.	MSN
What does CCP stand for?	Medicare coordinated care plans
What does the abbreviation MSA stand for in the Medicare program?	Medical Savings Account
Medigap insurance plans can be purchased as a supplement for individuals enrolled in	the Original Medicare Plan.
Medicare Administrative Contractors (MACs) process Medicare claims for which of the following?	Medicare beneficiaries
In what year did Medicare stop paying for all consultation codes from the CPT evaluation and management, except for telehealth consultation G-codes?	2010
CLIA is the abbreviation for	Clinical Laboratory Improvement Amendments
Under the Affordable Care Act, when must Medicare Part B providers file their claims?	within one calendar year after the date of service
An easy to perform low-risk lab test that can be performed by CLIA in the physician's office is called a(n)	waived test.
All laboratory work paid for by Medicare is regulated by	CLIA rules.
What is the abbreviation CCI for?	Correct Coding Initiative
CLIA is a federal law that established standards for	laboratory testing.
Paper claims cannot be paid before what day after receipt of the claim?	the 29th day
Who has the right to appeal denied Medicare claims?	Both patients and providers have the right to appeal denied Medicare claims.
CMS accepts only signatures that are	all of these are correct. handwritten electronic facsimiles of original written/electronic signatures
Applicants who have high medical bills and whose incomes exceed state limits may be eligible for health care coverage under a state __________ program.	medically needy
Under the Federal Medicaid Assistance Program, the federal government makes payment directly to	states.
Most individuals receiving TANF payments are limited to a __________-year benefit period.	five
Under Medicaid, optional services commonly include	prosthetic devices.
People classified as restricted status	must see a specific provider for treatment.
If family planning services are provided to a patient, what data element is affected?	family planning indicator
If services were provided in an emergency room, what place of service code is reported (Hint: Refer to Appendix A)?	23
The Medicaid Alliance for Program Safeguards	oversees states’ fraud and abuse efforts.
The national committee to coordinate Medicaid data elements on health care claims is called	NMEH.
To provide services to Medicaid recipients, physicians must sign a contract with the	HHS.
The federal government requires states to offer Medicaid benefits to children whose family income is under __________ percent of the poverty level.	133
FMAP is the abbreviation for	Federal Medicaid Assistance Percentage.
Medicaid beneficiaries must meet	both minimum federal requirements as well as any additional state requirements.
Under which program does the federal government send Medicaid funding to states?	FMAP
TANF is the abbreviation for	Temporary Assistance for Needy Families.
Individuals receiving financial assistance under TANF due to low incomes and few resources must be covered	by state Medicaid programs.
Which of the following assets must be taken into account to determine Medicaid eligibility?	all of these things must be considered stocks and bonds money in bank accounts cash surrender value of life insurance
CHIP is the abbreviation for	Children's Health Insurance Program.
Categorically needy people in the Medicaid program usually have	low incomes.
What does the abbreviation SSI stand for?	Supplemental Security Income
The __________ established the Temporary Assistance for Needy Families program.	Welfare Reform Act
The Welfare Reform Act of_________ tightened Medicaid eligibility requirements.	1996
Which program under Medicaid offers health insurance coverage for uninsured children?	CHIP
In a(n) __________, individuals are required to spend a portion of their income or resources on health care until they reach or drop below the income level specified by the state.	spend-down program
Under the Medicaid program, which of the following is true?	Categorically needy and medically needy do not have the same meaning.
If people receive employment income, what is the effect on eligibility for Medicaid?	They may qualify, depending on the income amount.
In a spend-down program, beneficiaries are required to	pay part of their monthly expenses.
Medicaid's spenddown program is in effect	on a state-by-state basis.
EMEVS stands for	Electronic Medicaid Eligibility Verification System.
In __________, the patient is required to see a specific physician and/or use a specific pharmacy.	restricted status
The Deficit Reduction Act of __________ created the Medicare Integrity Program (MIP).	2005
Providers in capitated managed care plans who are paid flat monthly fees	still must file claims with the Medicaid payer.
Physicians who wish to provide services for Medicaid beneficiaries enter into a contract with whom?	HHS
Most states have shifted Medicaid beneficiaries into which type of plan?	managed care plans
About what percentage of Medicaid recipients nationally are in managed care plans?	67%
To receive federal matching funds, states must cover certain services, including	all of these things must be covered. prenatal care emergency services vaccines for children
Which of the following services may not be covered under a state's Medicaid program?	cosmetic procedures
State Medicaid programs must provide coverage for all of the following except	vision benefits.
A Medi-Medi beneficiary's claim information is usually	sent by Medicare to Medicaid as the secondary payer.
__________ is referred to as the payer of last resort.	Medicaid
Which of the following statements is true?	Medicaid plans do not pay for a particular service if Medicare does not.
Dual eligibility refers to	Medicaid and Medicare.
Claims billed to Medicare which are automatically sent to Medicaid are called	crossover claims.
Individuals who are eligible for both Medicaid and Medicare benefits are called	both dual-eligibles and Medi-Medi beneficiaries.
Under the payer-of-last-resort regulation,	Medicaid pays last on a claim when a patient has other effective insurance coverage.
What organization advises CMS about HIPAA compliance issues related to Medicaid?	NMEH
The NMEH Workgroup advises which organization(s) about HIPAA compliance issues related to Medicaid?	CMS
Medicaid claims are usually submitted using the _________claim	HIPAA837P
Physicians who contract with Medicaid to provide services may not	all of these are correct. bill for services not provided bill for services that are not medically necessary submit claims for individual procedures that are part of a global procedure
NMEH is the abbreviation for	National Medicaid EDI HIPAA Workgroup.
A PCP is usually a	medical provider or practice.
The TRICARE plan that is an HMO and requires a PCM is	TRICARE Prime.
__________ receive priority at military treatment facilities.	Active-duty service members
A TRICARE For Life beneficiary must be at least __________ years old	sixty-five
TRICARE Prime is available to those eligible within __________ miles of a Primary Care Manager.	100
The TRICARE health care program is a covered entity and subject to privacy rules under	HIPAA
A person enrolled in CHAMPVA is responsible for __________ percent of covered charges	25
Nonparticipating TRICARE providers cannot bill for more than __________ percent of allowable charges.	115
Active-duty service members are automatically enrolled iN	TRICARE Prime.
For individuals enrolled in TRICARE For Life, the primary payer is	Medicare.
Decisions about an individual’s eligibility for TRICARE are made by the	branch of military service.
What should be checked on a patient's military ID card to confirm if it is valid?	the expiration date
Which of the following uniformed services is eligible for TRICARE without restrictions?	all are eligible PHS NOAA Navy
What program did TRICARE replace?	CHAMPUS
When creating TRICARE patient cases in a PMP, what information is included?	the sponsor's grade, branch of service, and status
Why can't providers contact DEERS directly regarding sponsors?	the information is protected by the HIPAA Privacy Act
Which of the following is the uniformed services member in a family qualified for TRICARE?	sponsor
Which of the following could make a decision about eligibility in TRICARE?	the Army
Where is information about TRICARE patient eligibility stored?	DEERS
What is the TRICARE term for coinsurance?	cost-share
What is the term for the maximum amount TRICARE will pay for a procedure?	TMAC
A nonparticipating provider in TRICARE sees a patient and provides a service with an allowed charge of $200. However, the provider charges the patient $250 for the service. Determine what amount the patient must pay.	$230
Which of the following is not something that providers who participate with TRICARE agree to?	Participate for every patient, every time.
A nonparticipating provider in TRICARE sees a patient and provides two services, one with an allowed charge of $120 and the other for $220. Calculate the maximum amount they may charge the patient.	$391
Who is responsible for the charges if a TRICARE managed care patient visits a provider who chooses not to join the TRICARE network?	the patient
If a provider chooses not to participate in TRICARE, they may charge no more than __________ percent of the allowable charge.	115
When does TRICARE's fiscal year run?	October 1 through September 30
Under TRICARE Prime, what payment is required for outpatient treatment at a military facility?	there is no deductible or copayment
What is the purpose of TRICARE Prime annual catastrophic cap?	to limit the maximum amount a sponsor will pay each year
Which of the following services are covered under TRICARE Prime?	all of these surgery maternity care outpatient care
TRICARE programs are subject to an annual __________, a limit on the total medical expenses that beneficiaries are required to pay in one year.	catastrophic cap
The husband of an active duty service member and an actual active duty service member have both arrived at a MTF. Who should be given priority?	the active duty service member
Which of the following may act as a PCM under TRICARE Prime?	military, civilian, or group provider
An active-duty service member has an annual catastrophic cap of $1,000 under TRICARE Prime and receives their first treatment of the year totaling $1,400. Calculate how much the member must pay.	$1,000
Once the catastrophic cap has been met, what percentage of the additional charges for covered services for that coverage year will TRICARE pay?	100 percent
Who coordinates and manages the medical care of individuals after they enroll in TRICARE Prime?	Primary Care Manager (PCM)
How much does a not active-duty family member have to pay to join TRICARE Prime for an individual?	$289.08
Geographic areas in the US that are designated to ensure medical readiness for active-duty members are known as	PSA (Prime Service Areas)
Individuals age__________ and over who are eligible for both Medicare and TRICARE are offered the opportunity to receive health care at a MTF through TRICARE for Life.	65
When TRICARE for Life beneficiaries receive treatment at a civilian network they must	pay a copay.
Determine the correct order of coverage between Medicare, Medicaid, and TRICARE for Life.	Medicare first, TRICARE second, Medicaid third
The TRICARE program that offers benefits to Medicare-eligible military retirees and family members is	TRICARE for Life.
Identify the correct order of payment when Medicare and TRICARE for Life coverage exist.	Medicare pays first, and TRICARE pays the remaining out-of-pocket expenses.
What must all enrollees in TRICARE for Life do?	be enrolled in Medicare Part A & B and pay Part B premiums
A fee-for-service plan available to people who have verifiable eligibility through DEERS and who enroll annually is known as	TRICARE Select.
Identify the correct order of payment when Medicaid and TRICARE for Life coverage exist simultaneously for one individual.	TRICARE pays first, and Medicaid covers the remaining expenses.
The program that offers benefits to veterans with 100 percent disability, as well as to their dependents or survivors, is	CHAMPVA.
Which of the following services is generally not covered by CHAMPVA?	dental care
Which organization is responsible for determining eligibility for the CHAMPVA program?	Department of Veterans Affairs (VA)
Which party is responsible for obtaining preauthorization under CHAMPVA?	the patient
Explain the terms with which providers who choose to participate in CHAMPVA must agree.	to accept CHAMPVA payment and the patient's cost-share payment as payment in full for services
In almost all cases, CHAMPVA is the	secondary payer.
Which program extends CHAMPVA benefits to spouses or dependents who are age sixty-five and over?	CHAMPVA For Life
Who is not eligible for CHAMPVA?	families of active duty members
All eligible beneficiaries in CHAMPVA possess a CHAMPVA Authorization Card, known as a(n)	A-Card.
Patients' out-of-pocket expenses are subject to a catastrophic cap of __________ per calendar year under the CHAMPVA program.	$3,000
What does a qualified independent contractor (QIC) ensure regarding TRICARE claims?	that services were medically necessary and appropriate
What is the basis for the submission of TRICARE claims to the regional contractor?	the patient's home address
What regulations cover the CHAMPVA, MHS, and TRICARE programs?	HIPAA
Identify the best practice for filing paper TRICARE claims.	Check with each payer for specific information required on the form.
Which of the following examples demonstrates an abuse activity versus a fraudulent one?	providing care that is of inferior quality
Once an application for Social Security Disability Insurance (SSDI) is filed, there is a __________ waiting period before benefits begin.	five month
A __________ is a denial of employer liability issued by the workers’ compensation insurance carrier.	Notice of Contest
An individual with a disability described as precluding heavy work has lost __________ of the capacity to push, pull, bend, stoop, and climb.	50 percent
Before an injured employee can return to work, a physician must write	a final report.
__________ provides workers’ compensation insurance coverage to employees of the federal government.	Federal Employees’ Compensation Act (FECA)
The classifications of pain used in workers’ compensation claims are	minimal, slight, moderate, severe.
A disability that limits a worker to jobs that are performed in an upright or walking position and that require no more than minimal effort is classified as	limitation to light work.
Vocational rehabilitation programs provide __________ for individuals with job-related disabilities.	training in a different job
For a widow or widower age fifty years or older who is disabled to qualify for Social Security Disability Insurance (SSDI), his or her spouse must have paid into Social Security for at least	ten years.
An employee who believes the work environment to be dangerous may file a complaint with the	Occupational Safety and Health Administration.
A patient presents with a form of cancer developed from radiation exposure during their work in a federal weapons facility. By which OWCP programs are they likely to be covered?	The Energy Employees Occupational Illness Compensation Program
A patient presents with an injury suffered while working on an offshore fishing ship. By which OWCP program are they likely to be covered?	The Longshore and Harbor Workers' Compensation Program
What was created to protect workers from health and safety risks on the job?	OSHA
The Federal Black Lung Program provides benefits for individuals who work in	coal mines.
Which types of services are offered by the programs administered by the OWCP?	vocational rehabilitation, medical treatment, and cash benefits for lost wages
Which of the following is an example of an injury that is generally not covered?	an injury resulting from an employee's failure to obey safety procedures
What is not covered by workers' compensation insurance?	injuries of self-employed individuals
Which of these accidents is an example of an unexpected result over time?	an employee develops a hearing disability after years in a noisy work environment
Which of the following is an example of an injury that is generally covered?	an injury due to heavy lifting
How is workers' compensation insurance funded under a state fund?	Companies pay premiums to a central state insurance fund.
What can develop due to workplace conditions or activities?	occupational diseases and illnesses
For a company to self-insure for workers' compensation, most states require you to	obtain authorization.
What is the most common method states use to determine wage-loss benefits?	They compensate employees based on a percentage of their salary before the injury.
What would most states pay when an individual is fatally injured on the job?	death benefits and funeral expenses
What classification of disability describes an individual who has lost 50 percent or more of the ability to lift, push, pull, bend, stoop, and climb?	precluding heavy work
What classification of disability describes an individual who has lost 25 percent of the ability for very heavy lifting?	precluding very heavy lifting
What type of pain may limit an employee on some work assignments but is generally tolerable?	slight pain
Which of these categories applies to a worker who is injured on the job, and requires treatment, but is able to return to work within several days?	injury without disability
Which law may allow individuals the right to request that a physician restrict a disclosure of their PHI for workers' compensation purposes?	none of these are correct; individuals do not have this right
What type of pain will markedly limit an employee's performance but is not intolerable?	moderate pain
Which of these categories applies to a worker who is injured on the job, requires treatment, and is unable to return to work within several days?	injury with temporary disability
What type of pain will force an employee to avoid any activities that will lead to the pain?	severe pain
An employee sprains her ankle on the job, resulting in a trip to a physician, but is cleared to return to work later that week. Which of the following categories describes this type of injury?	injury without disability
What type of codes must be included in ICD-10-CM coding to report the cause of an accident?	external causes
An employee suffers a bad fall in a factory and has to be trained to work in the administrative office for the company as a result of the injury. Which category describes this type of injury?	injury requiring vocational rehabilitation
Which of these categories applies to a worker who is injured on the job, requires treatment, is unable to return to work, and is not expected to be able to return to his or her regular job in the future?	injury with permanent disability
An employee breaks his arm on the job and requires treatment and a rehabilitation of several weeks before he can return to work. Which category describes this type of injury?	injury with temporary disability
An employee breaks his back on the job and is not expected to be able to return to the job in the future. Which category describes this type of injury?	injury with permanent disability
Who is allowed unrestricted access to workers' compensation files in most states?	employers and claim adjusters
What is the process of retraining an employee to return to the workforce called?	vocational rehabilitation
Who may file the first report of injury?	employer or physician
What does the physician of record file with the insurance carrier every time there is a substantial change in the patient's condition that affects disability status or when required by state rules and regulations?	progress report
What may a claimant be eligible for if a workers' compensation claim is not paid within the specified time?	interest on the payment or a late fee
What determination denies liability for an employee's workers' compensation claim?	Notice of Contest
When do temporary partial and temporary total disability benefits not cease?	the employee cooperates with request for medical examination
Supplemental Security Income provides financial assistance to individuals who	are qualified for welfare programs
Which of the following authorizes payroll deductions for the Social Security Disability Program?	FICA
An incomplete or inadequate medical report often leads to	the denial of a disability claim.
What type of programs provide partial reimbursement for lost income when a disability—whether work-related or not—prevents the individual from working?	disability compensation programs
What program helps to pay living expenses for people who are blind or have disabilities and those of low-income older people?	SSI

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