HCCA CHC - Enterprise Wide Billing and Reimbursement Questions and Answers with complete solutions

Medicare - Part C Insurance (Medicare Advantage) - Government managed care. Must be paying Part B Premiums to qualify. Def: Medicare Code Editor - As san electronic claim is being processed, it goes through the editor for accuracy. CMS 1500 Paper Billing Form/837P Electronic Billing Form - Used by Physicians to bill Def: Carrier - Part B, administers MD claims Def: Certificate of Medical Necessity - MD certification that service is necessary Def: CMS Allowable - Amount/maximum CMS allows for payment Def: Common Working File (CWF) - There are 9 across the USA; house all patient data and claims history. Def: Coordination of Benefits - Determining in what order a claim will be paid Def: Electronic Data Interchange (EDI) - Standards by which claims are transmitted Def: Fiscal Intermediary (FI) - Process for Medicare Part A Def: Grouper - Group codes for DRGs (diagnosis related groups)Def: Health Professional Shortage Area - Government recognized shortage of PCPs; MDs are given an incentive payment to work in these areas. Def: Local Coverage Determination - Region that is determined by CMS Def: Medicare Administrative Contractor (MAC) - Applies to Fiscal Intermediary and Carriers Def: Modifiers - 2 digit alpha-numeric code to modify payment Def: National Coverage Determination - National Coverage Determination trumps Regional/Local determination CMS 1450(UB-40) Paper Billing Form/837i Electronic Billing Form - Used by Inpatients/Hospitals to bill Def: Participating Provider/Supplier - Agrees to accept Medicare Allowable Amount as payment Def: Pricer - Determines how much will be paid for DRG reimbursement Def: Reassignment - Reassigning provider number for someone else to use for billing purposes Def: Remittance Advice - Tells you everything about payment (ex: reduced. paid, reason not paid, etc.) Def: Return to Provider (RTP) Report - How Carriers tell hospitals something is wrong with the claim they submitted. Def: Third Party Carrier - Whoever CMS contracted with to process claims Medicare - Part A Insurance - Inpatient Medicare - Part B Insurance - Outpatient/ MD Payment (members pay premium)Medicare - Part D Coverage - Prescription Drug Coverage Terminology - CPT - Current Procedural Terminology (CPT) Terminology - DRGs - Diagnosis Related Groups Terminology - HCPSC - Health Care Common Procedure Coding System Terminology: COPs - Conditions of Participation