CHAA Exam Reading Guide
Pre-Encounter – Part V
Pages 62-69
1. TRADITIONAL MEDICAID eligibility is evaluated on a ______regular basis. The Medicaid card is issued to the ______of each family, which will list the names and ______ID numbers for each person covered.
2. HMO MEDICAID contracts are determined by the ______and contracts are usually arranged so that claims are submitted to and paid by the HMO, which is reimbursed by Medicaid.
3. Medicaid is a ______payer with respect to Medicare.
4. WORKER’S COMPENSATION – services related to the result of ______related accidents or injuries and are paid by the employer or the employer’s workers compensation insurance company.
5. The ______must authorize worker compensation services. Employer must be contacted for ______. For billing, a claim number and the name of ______authorizing the service is required.
6. Key information to obtain in Worker’s Comp cases: ______and date of injury, type of ______, name of ______and ______person, their ______supervisor, Employee insurance information (in case injury is determined ______to be work related), and enter patient classification as “Worker’s Compensation” and whom the bill should be sent to.
7. AUTO INSURANCE – usually primary for ______victims of auto accidents.
8. If patient has no health insurance, then auto insurance would be ______.
9. If patient has Medicare or Medicaid, then auto insurance is ______.
10. Whenever possible, obtain the claim ______, ______address, and ______name and phone number.
11. LIABILITY – coverage for injuries resulting from ______of another party. For example, if the patient slipped and fell on a freshly mopped floor in a business and a sign was not posted that the floor was wet, the business would be liable. Healthcare facilities have their own policies regarding billing liability cases. There is no insurance ______for liability coverage.
12. COMMERCIAL INSURANCE – Insurance that is ______Medicare, Medicaid, Federal, State or County Programs. Blue Cross, Auto, PPO, HMO are considered ______insurance. Typically commercial beneficiaries are not required to select a ______(PCP) or go to a specific ______.
13. PREFERRED PROVIDER ORGANIZATIONS (PPOS) – PPOS are contracts between employers, ______, and ______.
14. Doctors and hospitals provide services at a ______in return for receiving large volumes of ______who are PPO members.
15. These doctors/hospitals are known as participating ______. Members do not have to select a PCP but must use a participating provider to obtain ______coverage. Choosing to go to a non-participating provider results in a coverage ______and the member has to pay more out of ______. Not all PPOs have PPO written on the ______.
16. Healthcare facilities usually have a ______of PPOs that the facility has contracts with available to the staff. PPO cards usually have the co-pay amounts for ER/UC office visits.
17. HEALTH MAINTENANCE ORGANIZATION (HMO) – insurance plans that strive to ______health care costs by requiring members to receive services at designated ______. Therefore, all services except those in ______situations must be provided or ______by a participating physician.
18. Members typically select a ______who is responsible for overseeing their healthcare and approves non-emergency services. Not all cards have ______on them.
19. Most HMOs issue cards to each family member with their ______instead of the policyholder’s. Many add a ______to the end of the policy holder to identify the cardholder’s relationship to the subscriber.
20. For example, the policy holder’s suffix could end in 00 or 01, with the spouse’s being 01 or 02, and other dependents being 02, 03, etc.
21. So if I am the policy holder, my suffix would be 00, my wife’s would be ______, my oldest child would then be ______, and my youngest child would be ______.
22. Many HMO cards display the ______’s name and phone number as well as co-pay information. Some HMOs specify that non-participating claims be sent to a different ______than participating claims.
23. TRICARE – healthcare program overseen by the ______of ______in cooperation with regional civilian contractors. FOUR TRICARE OPTIONS: Tricare ______is similar to an HMO.
24. Tricare ______, similar to a PPO that saves money for patients.
25. Tricare ______, a fee for service option the same as the former CHAMPUS
26. Tricare ______provides expanded medical coverage for Medicare-eligible beneficiaries.
27. CHAMPVA- health benefit program for families (the surviving spouse or children) of ______who died or were 100% disabled from a service connected injury.
28. All active duty service members are automatically enrolled in Tricare ______.
29. Tricare Standard is a cost sharing program for military families (and retirees) that shares most of the cost of treatment from civilian providers when beneficiaries cannot get care from a ______hospital or clinic.
30. Tricare has a series of rules to determine the ______payer. Generally Tricare is the ______payer to coverage from other health plans (HMO/PPO). Tricare is the ______payer if the other coverage is Medicaid or when a patient is eligible for Indian Health Service care.
31. Tricare for Life provides expanded medical coverage for:______eligible retirees, Medicare eligible ______members and widow/widowers, and certain former ______if they were eligible for Tricare before age 65.
32. Patient must have Medicare Part ______to be eligible for TFL.
33. You can usually verify basic information such as date coverage began, active/inactive status, and is the patient the policyholder or a dependant, what are deductibles, and co-pay information by ______.
34. The COMMON WORKING FILE (CWF) is a tool used to verify ______. It tells if a patient has ______and ______and their effective dates, whether they have switched from Medicare to Medicare Advantage (______), if the patient of spouse is ______and if they are covered by ______. If the patient was involved in an ______where the case is still open. The number of full and partial days remaining in the ______, the number of ______(SNF) days remaining, and if the patient is on ______care.
35. Medicaid can be verified through your ______website or their CWF Verification System. Subscriber ______is important concerning admission out of network. The ______number is also important in case a referral is required.
36. ______refers to the person being entitled to benefits and covered. The date they became eligible for the plan is important to know since info can change from month to month.
37. Certain services need authorizations and others do not. Some insurance companies require a CPT code, so have it available. This is referred to as ______.
38. Certain insurance companies require ______-______/______from the PCP prior to services being performed.
39. The total amount of money a policyholder will pay for medical services for himself and all dependants in a given time period is known as ______of ______. Once this limit is reached, benefits increase to 100%. Deductibles may or may not contribute to this.
40. The amount of eligible expenses a covered person must pay each year out of pocket before the plan pays for eligible benefits is known as the ______.
41. A pre-determined amount due at time of service required for physician visits, prescriptions, or hospital services are known as ______-______.
42. ____-______is the percentage amount of money a subscriber must pay toward medical costs once the deductible has been met, usually 80%/20%.
43. ______refers to purchasing a service or medical device separately which is typically a part of an HMO plan. For example, an HMO may ______behavioral health benefits, select a specific vendor to supply these services, and offer them on a stand alone basis.
44. ______refers to a limit that once reached, prevents any further funds from being available for coverage or any further services. Could be for a calendar year or a lifetime.
45. Procedures that are not included and covered on a plan are known as ______.
46. Be sure to ______to insure he/she is on the panel of providers for the patient’s insurance. This is especially important when a patient comes in unassigned and is treated by the physician ______.
47. ______of ______- refers to the way of determining the order in which benefits are paid and the amounts that are payable when a patient is covered by more than ______health care plan. The intention is to avoid ______of payments.
48. The National Association of Insurance Commissioners was established in 1970 to standardize coordination of benefit ______. Many states have adopted some or all of their regulations.
49. BIRTHDAY RULE - when a child is covered under both parent’s insurance, then the parent whose birthday (using month and day) occurs ______in the year is primary.
50. For example, if Steve’s son is covered by his and his wife Kathy’s insurance, and her birthday is in June and his is in November, then ______insurance will be primary. If both of their birthdays are in April and Steve’s is on the 11th and Kathy’s on the 21st, then ______will be primary.
51. When parents are not together and a court ______exists naming a certain parent responsible, then that parent’s plan is primary.
52. When parents aren’t together and no court decree exists, then:
a. the plan of the parent with ______is primary.
b. the plan of the ______(spouse with custody) is primary.
c. the plan of the parent who does not have ______
d. the plan of the stepparent (spouse of the non-custodial parent)
53. The primary plan is contacted ______for authorization and billed for all services rendered. The ______plan is billed after the primary plan has made the ______payment allowed. The secondary carrier calculates benefits as though there were ______other coverage. Then they pay the lesser of the calculated amount and the balance the primary carrier has submitted.
54. ______is when a payer agrees that conditions have been met based on the information given that all requirements have been satisfied to reimburse for medically necessary services.