Medicare

Some Medicare HMO enrollees are allowed to see specialists outside the "network" without going through a PCI. This is called

Self referring

A health insurance plan sold by private insurance companies to help pay for healthcare expenses not covered by Medicare is called a

Supplemental policy

Medicare Part A, the hospital insurance part of Medicare, is funded through

Taxes paid by employers and taxes withheld from employee's wages

If individuals do not sign up for Medicare Part B when first becoming eligible and later decide to enroll

The monthly premiums may be higher due to penalties

The second cost sharing requirement in Medicare Part B is an annual deductible of $135.00 , after which Medicare pays 80% of

Allowable charges

A private organization that contracts with Medicare to pay Part A and some Part B bills and determines payment to Part A facilities is called a

Fiscal intermediary "FI"

Medicare HICHs are typically in the format of nine numeric characters

Followed by one alpha character

A group of medical providers that skips the insurance company middleman and contracts directly with patients is referred to as a

Provider sponsored organization

The Medicare fee schedule is now based on a

Resource based relative value system

There are how many levels of the Medicare appeals process ?

5

This duration of time begins the day an individual is admitted to a hospital or SNF and ends when the beneficiary has not received care in a hospital or SNF for

60 days in a row

What percentage does Medicare pay of allowable charges after the annual deductible is met

80 percent

An individual must be eligible for Part A or B to enroll in

A Medicare Advantage Plan

Workers' Compensation would likely be a

A primary payer to Medicare

A form that Medicare requires all healthcare providers to use when Medicare does not pay for a service or is likely not to pay for a service is the

ABN "Advanced Beneficiary Notice"

The individual responsible for initial MSP "medicare secondary payer" development activities formerly performed by Medicare FIs and carriers

COB Contractor "Coordination of benefits contractor"

Exceptions to mandatory electronic claims filing include

Claims with paper attachments, demand bills, and claims when Medicare is the secondary payer

Medicare requires its beneficiaries to pay premiums, deductibles, and coinsurance, which is referred to as

Cost sharing

The term used when Medicare is not the primary payer and the beneficiary is covered under another insurance policy

MSP "medicare secondary payer"

Coverage requirements under Medicare, state that for a service to be covered, it must be considered

Medically necessary

Medicare Part B helps pay for

Medically necessary physician's services

Another name for Medicare Part C

Medicare Advantage Plans

Managed healthcare plans that offer regular Part A and Part B Medicare coverage and additional coverage for certain other services are called

Medicare Part C

The prescription drug coverage plan, which began in January 2006 , is called

Medicare Part D

Medicare Part C , previously called Medicare + Choice was renamed Medicare Advantage by the

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 MMA

The term used when another insurance policy is "primary" to Medicare is

Medicare Secondary Payer

Medicare "initial claims" do not include

Appeal requests

Part A coverage is available free of charge to "eligible" Medicare beneficiaries who

Are eligible to receive Social Security benefits

The duration of time Medicare uses for hospital and skilled nursing facility SNF services is called a

Benefit period

This is the duration of time during which a Medicare beneficiary is eligible for Part A benefits for services incurred in a hospital and / or skilled nursing facility "SNF"

Benefit period

The process of matching one set of data elements or category of codes to their equivalents within a new set of elements or codes is called a

Crosswalk

Most Medicare Part B beneficiaries pay for Part B coverage in the form of a " premium"

Deducted from their monthly Social Security check

In Medicare Part D, once the initial coverage limit is reached, beneficiaries are subject to another deductible, known officially as the "Coverage Gap" in which they must pay the full cost of medicine, more commonly known as

Donut hole

An individual qualifying for Medicare and Medicaid benefits is referred to as a

Dual Eligible

When an individual turns 65 and enrolls in Medicare, federal law forbids insurance companies from denying

Eligibility for Medigap policies for 6 months

For durable medical equipment DME to qualify for Medicare payment, it must be ordered by a physician for use

In the home and items must be reusable

LMRPs "Local Medical Review Policies" were replaced in 2003 by

LCDs "Local Coverage Determinations"

A health insurance plan sold by private insurance companies to help pay for expenses not covered by Medicare

Medigap

Medicare's definition of medical necessity must

Meet specific criteria

The deadline for submitting Medicare claims is

On or before December 31, of the calendar year following the date of service

The time period Medicare allows for enrolling in a Medicare supplement plan without penalty

Open Enrollment

The program that provides community based acute and long term care services to Medicare beneficiaries is called

PACE- Programs of All Inclusive Care for the Elderly

The acronym for the quality reporting system that provided an incentive payment for " eligible professionals " EPs who satisfactorily reported data on quality measures for covered services furnished to Medicare beneficiaries is

PQRI "Physician Quality Reporting Initiative"

Medicare was established by Congress in 1996 to provide financial assistance with medical expenses to

People older than 65

Under certain circumstances, a signed release of information form for Medicare beneficiaries can be

Valid for more than one year