Medical Insurance Chapters 11-17

Private fee-for-service (PFFS) plans are offered by private insurance companies in some regions of the country, and Medicare pays a pre-established amount of money each month to the insurance company, which decides how much it will pay for services. Such plans reimburse providers on a fee-for-service basis and are authorized to charge enrollees up to __________ percent of the plan's payment schedule.

115%

ICD-10-CM diagnosis codes are entered in Block 21 of the CMS-1500 claim. A maximum of __________ ICD-10-CM codes may be entered on a single claim.

12

The Balanced Budget Act of 1997 allows certain health care providers to withdraw from Medicare and enter into private contracts with their Medicare patients, which requires "opting out" of Medicare for at least __________ years for all covered items and services furnished to Medicare beneficiaries.

2 years

When entering a fee in Blocks 24F, 28, or 29, enter __________ in the cents column.

2 zeros

Secondary diagnoses codes are entered in Blocks __________ of the CMS-1500 claim.

21B-24L

BlueGeo provides global medical coverage for active employees and their dependents who spend more than __________ months outside the United States.

6

A Medicare benefit period begins with the first day of hospitalization and ends when the patient has been out of the hospital for __________ consecutive days.

60

Medicare lifetime reserve days, which total __________ days, are used once during a patient's lifetime and are usually reserved for use during the patient's final, terminal hospital stay.

60

When a workers' compensation claim is denied, the employee (or eligible dependents) can appeal the denial to the state workers' compensation board and undergo a process called __________, which is a judicial dispute resolution process in which an appeals board makes a final determination.

Adjudication

A(n) __________ claim has a payment correction, resulting in additional payment(s) to the provider.

Adjusted

Patients sign Block 13 of the CMS-1500 claim to instruct the payer to directly reimburse the provider. This concept is called __________.

Assignment of Benefits

Which is offered to members and marketed to small business owners as a way to provide coverage to employees?

Association Health Insurance

Which type of insurance is a contract between an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific vehicle-related financial losses during the term of the policy?

Automobile

BCBS fee-for-service __________ coverage includes minimum benefits, such as inpatient hospitalizations and diagnostic laboratory services.

Basic

The BCBS special accidental injury rider covers nonsurgical care rendered within 24 to 72 hours of the accidental injury. Surgical care is subject to any established contract __________ plan deductibles and copayments.

Basic

Workers' compensation insurance provides weekly cash payments and reimburses health care costs for covered employees who develop a work-related illness or sustain an injury while on the job. It also provides payments to qualified dependents of a worker who dies from a compensable illness or injury. Each state establishes a workers' compensation __________, which is responsible for administering workers' compensation laws and handling appeals for denied claims or cases in which a worker feels compensation was too low.

Board

Which is a comprehensive health care program for which the Department of Veterans Affairs shares costs of covered health care services and supplies with eligible beneficiaries?

CHAMPVA

Which insurance claim is submitted to receive reimbursement under Medicare Part B?

CMS-1500

Which insurance claim is submitted to receive reimbursement under Medicare Part C?

CMS-1500 or UB-04

Provider services for inpatient care are billed on a fee-for-service basis, and service results in a unique and separate charge designated by a __________ or HCPCS level II service/procedure code.

CPT

TRICARE Prime beneficiaries can receive care if they reside and work outside a military treatment facility __________ area, which is the region defined by code boundaries within a 40-mile radius of a military treatment facility.

Catchment

Which type of automobile insurance pays for damage to a covered vehicle caused by hitting an object or being hit during an automobile accident?

Collision

Which type of health insurance covers the medical expenses of individuals (e.g., private health insurance) and groups (e.g., employer group health insurance)?

Commercial

TRICARE enrollees use their uniformed services __________, which can be scanned each time they receive health care services.

Common access card

The Medicare Catastrophic Coverage Act of 1988 implemented Spousal Impoverishment Protection Legislation in 1989 to prevent married couples from being required to spend down income and other liquid assets (cash and property) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care. The spouse residing at home is called the __________ spouse.

Community

The base period of a disability policy usually covers 12 months and is divided into four __________ quarters.

Consecutive

Which is the sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment?

Critical pathway

When a patient seeks health care under the TRICARE program, sponsor information is verified in the __________ computer system, which contains up-to-date workforce personnel information.

DEERS

The Office of Workers' Compensation Programs (OWCP) administers programs that provide wage-replacement benefits, medical treatment, vocational rehabilitation, and other benefits to federal workers (or eligible dependents) who are injured at work or acquire an occupational disease. In which federal department is the OWCP located?

Department of Labor

The U.S. Labor Department's Mine Safety and Health Administration (MSHA) helps reduce deaths, injuries, and illnesses in U.S. mines through a variety of activities and programs. Which is an example of such an activity or program?

Develops and enforces safety and health rules that apply to all U.S. mines

Permanent disability refers to an ill or injured employee's __________ capacity to return to work.

Diminished

Which type of insurance is defined as reimbursement for income lost as a result of a temporary or permanent illness or injury?

Disability

HIPAA regulations require all payers to accept __________ attachments.

Electronic

To qualify for workers' compensation benefits, an employee must be injured while working within the scope of the job description, be injured while performing a service required by the employer, or develop a disorder that can be directly linked to employment, such as asbestosis or mercury poisoning. The worker does not have to be physically on company property to qualify for workers' compensation. Which is an example of an on-the-job injury that would qualify the employee for workers' compensation benefits?

Employee is injured when picking up reports for the office at the local hospital.

Which is an Office of Workers' Compensation Programs (OWCP) program?

Federal Black Lung Program

Which describes annual income guidelines established by the federal government?

Federal poverty level

The code reported in Block 21A of the CMS-1500 claim is the major reason the patient was treated by the health care provider. It is called the __________ diagnosis.

First listed

TRICARE deductibles are applied to the government's __________ year, which runs from October 1 of one year to September 30 of the next.

Fiscal

Individuals who wait until they turn 65 to apply for Medicare will cause a delay in the start of Part B coverage, because they will have to wait until the next __________ enrollment period, which is held January 1 through March 31 of each year, with Part B coverage starting on July 1 of that year.

General

Which is associated with "last resort" health insurance for individuals who cannot obtain coverage due to a serious medical condition?

High-risk pool

Which is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and their families?

Hospice

Diagnosis pointer letters A-L are preprinted in Block 21 of the CMS-1500 claim to allow for entry of __________ codes, and they are reported in Block 24E.

ICD-10-CM

The medical emergency care rider covers __________ treatment sought and received for sudden, severe, and unexpected conditions that if not treated would place the patient's health in permanent jeopardy or cause permanent impairment or dysfunction of an organ or body part.

Immediate

BCBS has a mandatory second surgical opinion (SSO) requirement necessary when a patient is considering elective, nonemergency surgical care. The initial surgical recommendation must be made by a physician qualified to perform the anticipated surgery. If a second surgical opinion is not obtained prior to surgery, the patient's out-of-pocket expenses may be __________.

Increased

Which is traditional fee-for-service health insurance that covers a portion of services with the patient paying the remaining costs?

Indemnity Insurance

When the patient is covered by other medical or liability policies, Medicaid reimburses providers __________.

Last

Commanders of selected military treatment facilities are called __________ for TRICARE regions.

Lead Agents

Which type of automobile insurance pays for accidental bodily injury and property damage to others, including medical expenses, pain and suffering, lost wages, and other special damages?

Liability

Which type of insurance covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured?

Liability

Temporary disability claims cover health care treatment for illness and injuries as well as payment for __________.

Lost wages

Which allows providers to electronically access the state's eligibility file to verify Medicaid eligibility?

MEVS

Participating providers contract to participate in a BCBS plan's preferred provider network (PPN), which is a program that requires providers to adhere to __________ care provisions.

Managed

Which includes health maintenance organizations and preferred provider organizations?

Managed care

The State Children's Health Insurance Program (SCHIP) was implemented in accordance with the Balanced Budget Act (BBA) to allow states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding __________ eligibility to include a greater number of currently uninsured children.

Medicaid

The federal name for the Title 19 medical assistance program is __________.

Medicaid

Which is a type of HMO that works in much the same way and has some of the same rules as a Medicare Advantage Plan, except that the individual receives health care from a non-network provider, and the original Medicare plan covers the services? The individual pays Medicare Part A and Part B coinsurance and deductibles.

Medicare Cost Plan

Which program pays for inpatient hospital critical care access, skilled nursing facility stays, hospice care, and some home health care?

Medicare Part A

Which program includes managed care and private fee-for-service plans that provide contracted care to Medicare patients?

Medicare Part C

Which program added prescription medication coverage to the original Medicare plan, some Medicare cost plans, some Medicare private fee-for-service plans, and Medicare medical Savings Account Plans?

Medicare Part D

BCBS corporations offer several federally designed and regulated Medicare supplemental plans that augment the Medicare program by paying for Medicare deductibles and copayments. These plans are usually identified by the word __________ on the patient's plan ID card.

Medigap

Medicare beneficiaries can also obtain supplemental insurance to help cover costs not reimbursed by the original Medicare plan. This type of coverage is called __________.

Medigap

Supplemental plans usually cover the deductible and copay or coinsurance of a primary health insurance policy. Which is the best known supplemental plan?

Medigap

The BCBS PPO plan is sometimes described as a subscriber-driven program, and BCBS substitutes the term subscriber or __________ for policyholder.

Member

Any time patients state that they receive Medicaid, they must present a valid Medicaid identification card because eligibility, in many cases, will depend on the patient's __________ income.

Monthly

A mother/baby claim is submitted for services provided to a baby under the __________ Medicaid identification number.

Mother's

Which was developed by the Centers for Medicare and Medicaid Services to assign the unique health care provider and health plan identifiers and to serve as a database from which to extract data?

NPPES

The CHAMPUS Reform Initiative (CRI) demonstration project offered military families a choice of how their health care benefits could be used. The DoD noted its successful operation and high levels of patient satisfaction, and determined that its concepts should be expanded to a __________ program.

Nationwide uniform

TRICARE __________ are available 24/7 for advice and assistance with treatment alternatives and to discuss whether a sponsor should see a provider based on a discussion of symptoms, and they will also discuss preventive care and ways to improve a family's health.

Nurse advisor

Effective July 31, 2001, the Energy Employees Occupational Illness Compensation Program (EEOICP) started providing benefits to eligible employees and former employees of the Department of Energy, its contractors and subcontractors, or to certain survivors of such individuals, and to certain beneficiaries of the Radiation Exposure Compensation Act. Which is responsible for adjudicating and administering claims filed by employees, former employees, or certain qualified survivors?

Office of Workers' Compensation Programs (OWCP)

Surgeon's charges for inpatient and outpatient surgery are billed according to a global fee, which means that __________ cover(s) presurgical evaluation and management, initial and subsequent hospital visits, surgical procedure, the discharge visit, and uncomplicated postoperative follow-up care in the surgeon's office.

One Charge

When the same payer issues the primary, secondary, or supplemental policies, the correct procedure for submitting the claim would be to submit __________.

One claim for all policies

Some BCBS contracts also include one or more riders, which are special clauses that stipulate additional coverage __________ the standard contract.

Over and above

Which is a combination Medicare and Medicaid option that combines medical, social, and long-term care services for frail people who live and receive health care in the community?

PACE

A simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass __________ programs offered by public health clinics and other entities that bill Medicare payers.

PPV and influenza virus vaccination

The CMS-1500 paper claim was designed to accommodate optical scanning of __________ claims.

Paper

Medicare special needs plans cover all Medicare __________ health care services for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management.

Parts A & B

Any provider who accepts a Medicaid patient must accept the Medicaid-determined payment as __________.

Payment in full

Which type of automobile insurance reimburses medical expenses for covered individuals, regardless of fault, for treatment due to an automobile accident?

Personal injury protection

Which is considered a nonphysician practitioner?

Physician Assistant

The forerunner of what is known today as the BlueCross plan began in 1929 when Baylor University Hospital in Dallas, Texas, approached teachers in the Dallas school district with a plan that would guarantee up to 21 days of hospitalization per year for subscribers and each of their dependents, in exchange for a $6 annual premium. This was considered a __________ plan.

Prepaid

The optical scanning process uses a device that converts __________ characters into text that can be viewed by an optical character reader (OCR).

Printed

An advance beneficiary notice of noncoverage (ABN) is a written document provided to a Medicare beneficiary by a supplier, physician, or provider, and the ABN must be presented to the patient __________.

Prior to providing the service/treatment.

Which is responsible for the surveillance of fraud and abuse activities worldwide involving purchased care for beneficiaries in the Military Health Care System?

Program Integrity Office

The BCBS outpatient pretreatment authorization plan (OPAP) requires preauthorization of outpatient physical, occupational, and speech therapy services. Other terms for OPAP include precertification and __________ authorization.

Prospective

Which program helps individuals who received Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the limit allowed, by requiring states to pay their Medicare Part A premiums?

Qualified disabled working individual

The TRICARE Management Activity (TMA) coordinates and administers the TRICARE program and is accountable for __________ health care provided to members of the uniformed services and their families.

Quality

A Medicare medical necessity denial is a denial of otherwise covered services that were found to be not __________.

Reasonable and Necessary

The Federal Black Lung Program provides medical treatment and other benefits for __________ conditions related to former employment in the nation's coal mines.

Respiratory

Which is the term for short-term care provided by another caregiver, so the usual caregiver can rest?

Respite Care

Medicare __________ is a type of Medigap insurance that requires enrollees to use a network of providers to receive full benefits, which may result in lower premiums for enrollees.

SELECT

For-profit corporations pay taxes on profits generated by the corporation's enterprises and pay dividends to __________ on after-tax profits.

Shareholders

When completing the CMS-1500, enter a __________ for the dollar sign or decimal in all charges or totals and parentheses surrounding the area code in a telephone number.

Space

Mary Smith is working full time and enrolled in Medicare Part A at age 65. She decided not to enroll in Medicare Part B at that time because her employer group health insurance coverage reimburses for physician and other outpatient encounters. Mary is eligible to enroll in Medicare Part B anytime during a(n) __________ enrollment period, which is a set time when individuals can sign up for Medicare Part B if they did not enroll when they applied for Medicare Part A.

Special

The Occupational Safety and Health Act of 1970 created the Occupational Safety and Health Administration (OSHA) to protect employees against injuries from occupational hazards in the workplace. OSHA and its state partners (of approximately 2,100 inspectors) establish protective __________, which are enforced. OSHA also reaches out to employers and employees by providing technical assistance and consultation programs.

Standards

In 1965 Congress passed Title 19 of the Social Security Act, establishing a federally mandated, __________-administered medical assistance program for individuals with incomes below the federal poverty level.

State

Which refers to the contractual right of a third-party payer to recover health care expenses from a liable party?

Subrogation

Which is a licensed physician in good standing who, according to state regulations, engages in the direct management of nonphysician practitioners whose duties are encompassed by that physician's scope of practice?

Supervising Physician

Which is a health care program for (1) active duty members of the military and their qualified family members, (2) CHAMPUS-eligible retirees and their qualified family members, and (3) eligible survivors of members of the uniformed services?

TRICARE

Which allows TRICARE Standard users to save 5 percent of their cost-shares by using health care providers in the TRICARE network?

TRICARE Extra

Which is the TRICARE managed care option similar to a civilian health maintenance organization?

TRICARE Prime

Which is the current program that makes cash assistance available, for a limited time, for children deprived of support because of a parent's absence, death, incapacity, or unemployment?

Temporary Assistance for Needy Families

Hospital inpatient charges are reported on the __________ claim.

UB-04

BCBS Healthcare Anywhere coverage allows members of the independently owned and operated BCBS plans to have access to health care benefits throughout the __________, depending on their home plan benefits.

United states and the world

A(n) __________ claim is one that Medicaid should not have originally paid, and results in a deduction from the lump-sum payment made to the provider.

Voided

BlueShield plans were created as the result of a resolution passed by the House of Delegates at an American Medical Association meeting in 1938. This resolution supported the concept of __________ health insurance that would encourage physicians to cooperate with prepaid health care plans.

Voluntary

Postoperative complications requiring a return to the operating room for surgery related to the original procedure are billed as an additional procedure, and the additional procedure is linked to __________.

a new diagnosis that describes the complication

Survivor benefits claims provide death benefits to eligible dependents. These benefit amounts are calculated according to the employee's earning capacity __________.

at the time of the illness or injury

Which include sponsors and dependents of sponsors?

beneficiaries

Which are located at military treatment facilities and are available to answer questions, help solve health care-related problems, and assist beneficiaries in obtaining medical care through TRICARE?

beneficiary counseling and assistance coordinators

The BlueCard and BlueCard Worldwide programs enable members to obtain health care services while traveling or living in another BCBS plan's service area, which means they can receive __________.

benefits of their home plan contract and access to local provider networks

The TRICARE benefit that protects beneficiaries from devastating financial loss due to serious illness or long-term treatment by establishing limits over which payment is not required is called the __________ cap benefit.

catastrophic

OSHA has special significance for those employed in health care because employers are required to obtain and retain manufacturers' Material Safety Data Sheets (MSDS), which contain information about __________ used on site. Training employees in the safe handling of these substances is also required.

chemical and hazardous substances

Group health insurance is available through employers and other organizations, and all or part of the premium costs are paid by employers. Employer-based group health insurance __________.

covers all employees, regardless of health status, and cannot be canceled if an employee becomes ill

Which are located at military treatment facilities to assist beneficiaries in resolving health care collection-related issues?

debt collection assistance officers

Which is filed with the workers' compensation board to document any significant change in the worker's medical or disability status?

detailed narrative progress/supplemental report

The MUE project was implemented by CMS as part of the NCCI to improve the accuracy of Medicare payments by __________.

detecting and denying unlikely Medicare claims on a prepayment basis

Which consists of routine pediatric checkups provided to all children enrolled in Medicaid, including dental, hearing, vision, and other screening services to detect potential problems?

early and periodic screening, diagnostic, and treatment

A military treatment facility (MTF) is a health care facility operated by the military that provides inpatient and ambulatory care to eligible TRICARE beneficiaries. Which is an example of ambulatory care?

emergency department treatment

The BlueCross BlueShield Federal Employee Program (FEP) is a(n) __________ health benefits program established by an Act of Congress in 1959.

employer-sponsored

By 1932 some plans modified the prepaid plan concept and organized community-wide programs that allowed the subscriber to be hospitalized in one of several member hospitals in accordance with signed contracts to provide services __________.

for negotiated special rates

BCBS indemnity coverage offers choice and flexibility to subscribers who want to receive a full range of benefits along with the __________.

freedom to use any licensed health care provider

When reporting procedures and services on the CMS-1500, list one procedure per line, starting with line one of Block 24. To report more than six procedures or services for the same date of service, __________.

generate a new claim to enter more procedures/services

The Longshore and Harbor Workers' Compensation Program, administered by the U.S. Department of Labor, provides medical benefits, compensation for lost wages, and rehabilitation services to longshoremen, harbor workers, and other maritime workers who are __________.

injured from or suffer diseases during employment

Block 33 of the CMS-1500 claim requires entry of the name, address, and telephone number of the billing entity, which is the __________.

legal business name of the practice

Vocational rehabilitation claims cover expenses for vocational retraining for both temporary and permanent disability cases. Vocational rehabilitation retrains an ill or injured employee so he or she can return to the workforce. The employee __________ of resuming the position held prior to the illness or injury.

may be incapable

Health Affairs (HA) refers to the Office of the Assistant Secretary of Defense for Health Affairs, which is responsible for __________.

military readiness and peacetime health care

The Merchant Marine Act (or Jones Act) provides seamen with the same protection from employer __________ as the Federal Employment Liability Act (FELA) provides railroad workers.

negligence

Which is issued by a military treatment facility that cannot provide needed care to TRICARE Standard beneficiaries and means the beneficiary can seek care from a civilian provider and reimbursement will be approved?

nonavailability statement

Which of the following health care professionals is permitted to bill a physician when that physician provides direct supervision of procedures/services?

nonphysician practitioner

Programs of All-inclusive Care for the Elderly (PACE) use a capitated payment system to provide a comprehensive package of community-based services as an alternative to institutional care for persons age 55 or older who require a(n) __________ level of care.

nursing facility

First Report of Injury forms are completed by the __________ when treatment for a work-related illness or injury is sought.

physician or other health care provider

Who is required to personally sign the original and all photocopies of reports submitted to the workers' compensation board?

physician or other health care provider

Medicare will award an assigned claim conditional primary payer status and process the claim when a __________.

plan considered primary to Medicare issues a denial of payment that is under appeal

Which are decision-making tools used by providers to determine appropriate health care for specific clinical circumstances?

practice guidelines

Which is assigned to a TRICARE Prime sponsor and is part of the TRICARE provider network?

primary care manager

Which is the special group that requires states to pay Medicare premiums, deductibles, and coinsurance amounts for individuals whose income is at or below 100 percent of the federal poverty level and whose resources are at or below twice the standard allowed under SSI?

qualified Medicare beneficiaries

Which program helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles, and coinsurance amounts?

qualified Medicare beneficiary program

Which is the special group that requires states to pay Medicare Part A premiums for certain disabled individuals who lose Medicare coverage because of work?

qualified working disabled individuals

Nonprofit corporations are charitable, educational, civic, or humanitarian organizations whose profits are __________.

returned to the nonprofit corporation

TRICARE regions are served by one or more __________ who assist TRICARE sponsors with health care needs and answer questions about the program.

service centers

BlueCross plans originally covered only hospital bills, and BlueShield plans covered fees for physician services, and there was close cooperation between the plans that resulted in joint ventures where the two corporations were housed in one building. In these joint ventures, BlueCross BlueShield (BCBS) __________.

shared one building and computer services but maintained separate corporate identities

When entering codes for diagnoses on a CMS-1500 claim, qualified diagnosis codes (e.g., possible, probable) are never reported. Instead, codes for the patient's __________ are entered.

signs or symptoms

Which program helps low-income individuals by requiring states to pay their Medicare Part B premiums?

specified low-income Medicare beneficiary

The portion of the Medicaid program paid by the federal government is called the Federal Medical Assistance Percentage (FMAP) and is determined annually for each state using a formula that compares __________ average per capita income level with the national average.

state

Which is a quasi-public agency that provides workers' compensation insurance coverage to private and public employers and acts as an agent in state workers' compensation cases involving state employees?

state insurance fund

Federal regulations require Medicaid to establish and maintain a(n) __________ program, which safeguards against unnecessary or inappropriate use of Medicaid services.

surveillance and utilization review

If a patient is covered by two different policies, the usual procedure for submitting a claim would be __________.

to submit to the primary payer first, followed by submitting to the secondary after primary payment is received

Which term is used to describe the Army, Navy, Air Force, Marines, and Coast Guard, Public Health Service Commissioned Corps, and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Corps?

uniformed services