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