Understanding Health Insurance - Chapter 15

When mother/baby claims are submitted under the mother's Medicaid identification number, coverage is usually limited to the baby's first: 1) 30 days of life 2) 45 days of life 3) 10 days of life 4) 15 days of life

10 days of life

To be eligible for Medicaid, the family income of pregnant women and children under age 6 must be at or below ______ percent of the federal poverty level (FPL). 1) 116 2) 133 3) 125 4) 107

133

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. 1) 18 2) 19 3) 21 4) 25

21

If applicable, enter the Medicaid preauthorization number in Block ____ of the CMS-1500. 1) 23 2) 1a 3) 25 4) 32a

23

To indicate that a provider accepts assignment on the CMS-1500 claim form, an X is placed in the YES box of Block: 1) 10a 2) 27 3) 11d 4) 20

27

The CMS-1500 claims instructions for the State Children's Health Insurance Program (SCHIP) are developed by: 1) A Medicare administrative contractor 2) A clearinghouse selected by the state 3) A payer selected by the state 4) Centers for Medicare and Medicaid Services

A payer selected by the state

An adjusted claim has a payment correction, resulting in a(n): 1) Additional payment to the provider 2) Penalty to be paid by the provider 3) Reduction in payment to the provider 4) Resubmission of a corrected claim

Additional payment to the provider

Medicaid is jointly funded by federal and state governments, and each state 1) Establishes uniform eligibility standards. 2) Adopts the federal scope of services. 3) Administers its own Medicaid program. 4) Implements managed care for payment.

Administers its own Medicaid program.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services are available to: 1) All children enrolled in Medicaid 2) Qualified individuals over age 65 3) Individuals who are dual eligible 4) Children under the age of 12

All children enrolled in Medicaid

The Federal Medical Assistance Percentage (FMAP) is determined annually for each state using a formula that compares the state's: 1) Level of assistance required last fiscal year with the level of federal assistance 2) Average per capita income level with the national average 3) Average number of families with children under 6 with the national average 4) Percentage of individuals applying for assistance with the national percentage

Average per capita income level with the national average

The federal government provides matching funds for this population. 1) Categorically needy 2) Medically needy 3) Special groups 4) Qualifying individual

Categorically needy

Which is considered a voided claim? 1) Claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider 2) Claim that underwent review to safeguard against unnecessary or inappropriate use of Medicaid services or excess payments 3) Claim that has a negative balance for which the provider receives no payment until amounts exceed the negative balance amount 4) Claim that has a payment correction submitted on it, which results in additional reimbursement being made to the provider

Claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider

Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are 1) Provided when other equally effective treatments are available or suitable. 2) Recognized as being inconsistent with generally accepted standards. 3) Consistent with the patient's symptoms, diagnosis, condition, or injury. 4) Furnished primarily for the convenience of the recipient or the provider.

Consistent with the patient's symptoms, diagnosis, condition, or injury.

A voided claim is one that Medicaid should not have originally paid, and results in a(n): 1) Deduction from the lump-sum payment to the provider 2) Additional payment made to the provider by the payer 3) Penalty to be paid by the provider to the third-party payer 4) Resubmission of a corrected claim to the payer

Deduction from the lump-sum payment to the provider

Individuals entitled to Medicare and some other type of Medicaid benefit are referred to as: 1) Dual eligibles. 2) Double dippers. 3) Dual covered. 4) Government eligibles.

Dual eligibles

Individuals who are eligible for both Medicare and Medicaid coverage are called 1) Participating providers. 2) Medicaid allowables. 3) Dual eligibles. 4) PACE participants.

Dual eligibles.

State legislatures may change Medicaid eligibility requirements 1) To clarify services and payments only. 2) During the year, sometimes more than once. 3) As directed by the federal government. 4) No more than once during each year.

During the year, sometimes more than once.

Which is considered a mandatory Medicaid service that states must offer to receive federal matching funds? 1) Family planning services and supplies 2) Rehabilitation and physical therapy services 3) Nursing facility services for those under age 21 4) Transportation services

Family planning services and supplies

Services provided to dual eligibles that are covered by both programs are paid: 1) First by Medicare and the difference by Medicaid 2) 50 percent by Medicare and 50 percent by Medicaid 3) 70 percent by Medicaid and 30 percent by Medicare 4) First by Medicaid and the difference by Medicare

First by Medicare and the difference by Medicaid

The system used to check Medicaid eligibility is known as: 1) DEERS 2) Point-of-service 3) MEVS/REVS 4) Tenn Care

MEVS/REVS

When the patient has multiple sources of insurance coverage, the payer of last resort is: 1) Medigap 2) Medicaid 3) Medi-Medi 4) Medicare

Medicaid

Services that are the prevailing standard and consistent with professional medical standards are considered: 1) Medically required 2) Medically recommended 3) Medically needy 4) Medically necessary

Medically necessary

When a patient is covered through Medicare and Medicaid, which coverage is primary? 1) Medicaid. 2) It depends on which policy was in effect the longest. 3) Ask the patient. 4) Medicare.

Medicare

Preauthorization is required for all: 1) Nonemergency hospitalizations 2) Postoperative care episodes 3) Emergency hospitalizations 4) Routine physician office visits

Nonemergency hospitalizations

What is the phrase that is used to indicate that Medicaid is always the secondary insurer? 1) Never pay first. 2) Other insurers always first. 3) Balance payer only. 4) Payer of last resort.

Payer of last resort.

When a patient has Medicaid coverage in addition to other, third-party payer coverage, Medicaid is always considered the 1) Medically necessary service. 2) Remittance advice. 3) Adjusted claim. 4) Payer of last resort.

Payer of last resort.

The following services require preauthorization except: 1) Elective inpatient admissions 2) Emergency inpatient admissions 3) More than one preoperative day 4) Physician services

Physician services

Methods used to access the Medicaid eligibility system are: 1) Email, point-of-service device 2) Point-of-service device, automated voice response, computer 3) Automated voice response, point-of-service device, email 4) Computer, email, point-of-service device

Point-of-service device, automated voice response, computer

Which process does the surveillance and utilization review subsystem (SURS) use to monitor both the use of health services by recipients and the delivery of health services by providers? 1) Postpayment review 2) Accreditation 3) Quality assurance program 4) Concurrent review

Postpayment review

Which allows providers to electronically access the state's eligibility file using a point-of-service device, computer software, or an automated voice response system? 1) NPPES 2) REVS 3) RAC 4) VAN

REVS

What does the provider receive upon eligibility verification through the Medicaid eligibility verification system (MEVS)? 1) Explanation of benefits 2) Receipt ticket 3) Medicaid Summary Notice 4) Remittance advice

Receipt ticket

Which does Medicaid use to communicate information about claims processing and reimbursement to the provider? 1) Assignment of benefits 2) Remittance advice 3) Claims adjudication 4) Explanation of benefits

Remittance advice

Which allows states to create or expand existing insurance programs to include a greater number of children who are currently uninsured? 1) TWWIA 2) SSDI 3) FMAP 4) SCHIP

SCHIP

Which is the assumption of an obligation for which another party is primarily liable? 1) Arbitration 2) Adjudication 3) Subrogation 4) Outsourcing

Subrogation

Which makes cash assistance available, for a limited time, for children deprived of support because of a parent's absence, death, incapacity, or unemployment? 1) SCHIP 2) TANF 3) AFDC 4) PACE

TANF

Which requirements are used to determine Medicaid eligibility for mandatory categorically needy eligibility groups? 1) EPSDT 2) TANF 3) AFDC 4) PACE

TANF

Aid for Families with Dependent Children is now known as: 1) Social Security for Children. 2) Temporary Assistance for Needy Families. 3) Qualified Medicare beneficiaries. 4) Qualifying individual.

Temporary Assistance for Needy Families.

Which established a state-administered medical assistance program for individuals with incomes below the federal poverty level? 1) Title 9 of the Public Health Service Act 2) Title 18 of the Social Security Amendments of 1965 3) Title 16 of the Social Security Act 4) Title 19 of the Social Security Act

Title 19 of the Social Security Act

A Medicaid claim that should not have originally been paid is known as a(n): 1) Rejected claim 2) Voided claim 3) Suspended claim 4) Adjusted claim

Voided claim