NCE PRACTICE EXAM

Tricare covers active duty service members and their families and also surviving spouses and retired active duty service members under certain plans.

Medicaid is administered by the state governments, in accordance with federal requirements, and is for low income, disabled or individuals with complex medical needs and has a sub-section for a children's insurance plan in some states.

CMS is Centers for Medicare and Medicaid which is run by the government and not private insurance.

The worker/patient must fill out a worker's compensation claim. His private insurance will not cover a work-based injury. The insurance company will be notified because there is a specific box on the CMS-1500 form that asks whether this injury was related to work.

PPO plans cover out of network visits, but usually at a significantly reduced rate, e.g. 50% coverage instead of 80%. HMO plans do not allow for visits out of network.

365 days or 1 year is timely filing for Medicare. Other insurances, such as Humana, have shorter timely filing periods of 90 days. Claims can be submitted to Medicare after 1 year but will be denied for timely filing limit and no payment will be received.

A usual and customary amount (U&C) must be set and charged the same amount to all insurance carriers. The U&C amount can change and should be set to higher than the highest paying insurance company in order to capture complete reimbursement.

An advance beneficiary notice (ABN) must be filled out before a patient receives non-covered services. This form must include a breakdown of all costs and the reason why it will not be covered. CMS-1500 is used to submit claims and beneficiaries never see it.

It is illegal to bill Medicaid patients without signed consent. The chiropractor should refund her money and bill her insurance properly. Even if a service is not covered when billed to Medicaid, the balance cannot be billed to the patient afterwards.

According to the OIG, you may waive the patient's deductible for Medicare if the patient demonstrates financial hardship. You must keep a record of this form in the patient's records.

Accessing your neighbor's daughter's information in the EHR violates HIPAA's minimum necessary requirement, where individuals only access the minimum amount of protected health information needed to do their job. In instances where there is a "break the glass" safety feature in your hospital's EHR, this may send an alert to compliance and you will be subject to discipline or a more serious employment action.

You do not actually have to do anything. You can refute the RAC letter and provide documentation, file an appeal or do nothing and the RAC will recoup their payments out of your next check from Medicare.

Under the Privacy Rule, HIPAA allows for 30 days and an additional 30 days can be added to the time period if you inform the patient in writing.

Coinsurance is a percentage of the contractual allowance, while copays are a flat set amount. The contractual allowance is the amount the provider was reimbursed directly plus the patient's responsibility, so the contractual discount is the usual and customary amount (U&C) minus reimbursement and minus patient's responsibility.

Clearinghouses collect claims data and send it in a lump file to each individual insurance for reimbursement. Clearinghouses also receive and distribute ERAs and can provide additional services, such as patient statements if requested, but do not provide collections services.

Premiums are paid monthly to insurance to continue coverage. Deductibles must be paid before insurance begins to pay for medical services. Copays are flat fees for each doctor's visit and coinsurance is a percentage of the allowed amount that must be paid in addition to copays and deductibles.

CO-1 means that the patient has not paid their deductible, so the allowed amount should be transferred to the patient for them to pay.

Relative value units are combined with GPCIs and conversion factors to create the Medicare Fee-for-Service fee schedule.

Medicare requires date of transfer, not date of surgery, as the beginning of the post-operative period. This information goes in box 19.

Use code 7 for replacement claims and use the original claim number (ICN) in that box.

Loops and segments crosswalk to CMS-1500 boxes.

The provider is enrolled as a sole proprietor and only has an individual NPI. Sole proprietors can use their individual NPI as both a group and an individual NPI, but if they ever hire someone it makes billing a bit messy. The group could also be put into box 24J, but since we're talking about individuals and not organizations, this is not the most likely cause.

Medicare is always primary and Medicare will send an RA to Aetna (which may or may not make it, so it's always good to follow up with another claim and COB to Aetna after receiving your remit from Medicare).

11 is the Place of Service (POS) that is billed for an office. 12 POS is a home visit.

A 25 modifier must be attached to the evaluation and management if documentation supports and it was a significant and separate service apart from the injection.

Comprehensive metabolic panel includes Albumin, Bilirubin, Calcium, Carbon dioxide Chloride, Creatinine, Glucose, Phosphatase, Potassium, Protein, Sodium, ALT, AST, BUN. This is an example of unbundling.

Modifier 57 indicates that the evaluation and management service resulted in a decision for surgery.

The procedure has a 90 day global period. The global payment covers all related procedures to the initial procedure within those 90 days, including dressing changes.

One charge is for the facility and the other is for the reading of the X-ray. Radiologists (MDs) are not always the ones performing the actual X-ray, which is mostly X-ray technicians employed by the hospital. Then the radiologist both performs and interprets the X-ray and there is only one charge.

Professional fee visits are reimbursed on a fee schedule for each CPT code. ICD-10 CM diagnosis codes are not reimbursable in the professional setting but are grouped as Diagnosis Related Groups (DRGs) in inpatient setting and facility reimbursement is based off DRGs. ICD-10 PCS are procedure codes used in an inpatient setting but receive no reimbursement.