Chapter 15 and 16 Questions
TRICARE non-participating providers are subject to a limited charge of? Above the TRICARE fee schedule for participating providers
15%
States that opt to include a medically needy eligibility group in their Medicaid program are required to include certain children who are under the age of ? and who are full time students
21
Who assists TRICARE sponsors with information about the health program along with other matters affecting access to healthcare like appointment schedules
Beneficiary services representative
What is the abbreviation for the computer system that contains up-to-date defense department workforce personal information and is used to verify TRICARE eligibility
DEERS
The number of TRICARE regions has? Since originally established
Decreased
Commanders of selected military treatment facilities for tricare regions are called
Lead agents
TRICARE plans are primary to
Medicaid
Programs of all-inclusive care for the elderly (PACE) work to limit out of pocket costs to beneficiaries by
Not applying deductibles copayments or other cost sharing
The managed care option that is similar to a civilian HMO is called TRICARE
Prime
The entity responsible for the prevention, detection, investigation, and control of TRICARE fraud, waste and abuse if the
Program Integrity Office
Claims are submitted to the TRICARE
Regional contractors
Which allows states to create or expand existing insurance programs to include a greater number of children who are currently uninsured?
SCHIP
A critical path way is the
Sequence of activities that can normally be expected to result in the most cost effective clinical course of treatment
CHAMPUS was replaced by TRICARE
Standard
What is included in a couple's combined resources, according to the Spousal Impoverishment Protection legislation?
Summer home
Which requirements are used to determine medicaid eligibility for mandatory categorically needy eligibility groups
TANF
The healthcare program for active duty members of the military and their qualified dependence is called
TRICARE
Which TRICARE option is a fee for service plan
TRICARE Standard
Which office coordinates and administers the tricare program and is accountable for the quality of healthcare provider to members of the uniform services and they're eligible dependents
TRICARE management activity
the organization responsible for coordinating and administering the tricare program is the
TRICARE management activity
In which option are active military personnel required to enroll
TRICARE prime
TRICARE nurse advisors are available 24/7 to assist with
Treatment alternatives and recommendations for care
one way the federal government verifies receipt of medicaid services by a patient is by use of
a monthly survey sent to a sample of medicaid recipients requesting verification
TRICARE has established a good-faith policy for assigned claims to protect the provider when
a patient presented an id card and it turned out to be invalid
the term sponsor is used to describe
active duty, retired or deceased military personnel
Medicaid is jointly funded by federal and state governments and each state
administers its own medicaid program
If a TRICARE Prime beneficiary seeks care from a facility outside of the tratment area without prior approval,the point-of-service option is activated. This will result in what cost(s) to the beneficiary?
an annual deductible plus 50 percent or more of visit or treatment fees
Which is subject to Medicaid preauthorization guidelines?
any extension of inpatient acute care hospital days
Temporary Assistance to Needy Families (TANF)program provides
cash assistance on a limited-time basis for children deprived of support
Which is considered a voided claim
claim that medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider
lead agents of selected military treatment facilities (MTFs) hold what rank
commander
Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are
consistent with the patient's symptoms, diagnosis, condition, or injury
A military treatment facility (MTF) catchment area is
defined by code boundaries within a 40-mile radius of an MTF
Individuals who are eligible for both Medicare and Medicaid coverage are called
dual eligibles
State legislatures may change Medicaid eligibility requirements
during the year, sometimes more than once
what special handling is required for tricare hospice claims
enter the words HOSPICE claim on the envelope
which services are exempt from medicaid copayments
family planning and emergency services
Which is considered a mandatory Medicaid service that some states must offer to receive federal matching funds
family planning services and supplies
The medicaid program is
federally mandated and state administered
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services are offered for which medicaid-enrolled population
individuals under the age of 21
To receive matching funds through Medicaid, states must offer what coverage?
inpatient hospital services
medicaid policies for eligibility are complex and vary among states thus, a person who is eligible for medicaid in one state
may not be eligible in another state
the entire health care system of the US uniformed services is known as the
military health services system (MHSS)
a primary care provided in a medicaid primary care management (PCCM) plan differs from an HMO primary care provider in that the medicaid primary care provider is
not at risk for the cost of care provided
tricare outpatient claims will be denied if they are filed more than
one year after the date of service
When a patient has Medicaid coverage in addition to other third-party payer coverage, medicaid is always considered the
payer of last resort
An individual whose income is at or below 100 percent of the federal poverty level (FPL) and has resources at or below twice the standard allowed under the ssi program may receive assistance from medicaid to pay for medicare premiums, deductibles, and coinsurance amounts as a
qualified medicare beneficiary (QMB)
When a patient has become retroactively eligible for medicaid benefits, any payments made by the patient during the retroactive period must be
refunded to the patient by the practice
A Medicaid card issued for the "unborn child of..." is good for
services that promote the life and health of the unborn child
a medicaid care issued for the unborn child of.. is good for
services that promote the life and health of the unborn child
`A medicaid voided claim
should not have been paid originally
The conversion of champus to tricare was the result of
successful champus reform initiative (CRI) demonstration project
Which TRICARE option has the highest out of pocket costs of all the tricare plans
tricare standard