– may appeal claim decisions
medical expenses are shared between TRICARE and the beneficiary.
Most enrollees pay annual deductibles
families of active-duty members pay 20 percent of outpatient charges.
– Retirees/families, former spouses, families of deceased pay 25% cost-share for outpatient services.
Unproven (experimental) procedures or treatments
Routine physical examinations or foot care (!?)
All active-duty svc members are automatically enrolled in TRICARE Prime, and do not have the option of choosing from among additional TRICARE options.
– More expensive than TRICARE Prime/ Less costly than TRICARE Standard.
-Indiv. already enrolled in Medicare HMO may not participate in TRICARE for Life;
– Dependents of a veteran who was totally and permanently disabled due to a service-connected condition at the time of death.
– Survivors of a veteran who died as a result of a service-related disability
– Survivors of a veteran who died in the line of duty
includes spouses or unmarried children
Include Inpatient Services (hospital) and Outpatient Services (maternity, Family planning, cancer screenings, cholesterol, HIV testing, Immunizations, Well-check to 6 yr, DME, Mental health care, Ambulance services, diagnostic tests, hospice)
Experimental or investigational procedures
Organ and bone marrow transplants
Durable medical equipment in excess of $300
– out-of-pocket costs subject to a catastrophie cap of $3,000/calendar yr. (then CHAMPVA pays 100%)
-cost-share of 25 percent (75 for CHAMPVA / 25 for indiv)
– Beneficiary is responsible for costs not covered by CHAMPVA
-Supplemental policies purchased to cover deductibles, cost shares and other services.
– CHAMPVA for Life benefits are payable after payment by Medicare or other third-party payers.
-Eligible beneficiaries must be 65+ & enrolled in Medicare Parts A & B; CHAMPVA acts as primary payer
– TRICARE South
– TRICARE West
Plus another region for International Claims
Claims are submitted to regional contractor based on the patient’s home address
Must be filed within 1 year of date of service or discharge.
2x/month; 1x/month; every 2 months; or every 6 months
– those eligible but don’t receive TANF
– Those receiving Foster care or adoption assistance under SS Act
– Children undr 6 yrs of age from low-income families
– Some people who lose cash assistance when their work income or SS benefits exceed allowable limits
– Infants born to Medicaid-eligible pregnant women
– People 65+, legally blind or disabled who receive SSI
– Certain low-income Medicare recipients
Funded by Fedl. Govt. and the states.
Provides coverage for preventive svcs., phys. svcs, inpatient & outpatient svcs.
1. Medical History (physical & mental)
2. physical exam
4. Lab tests
5. Health education
9. Other necessary services
Income & Asset Guidelines
Spend Down Programs
Medicaid Fraud and Abuse
– not medically necessary services
– Experimental or investigational procedures
– cosmetic procedures
– they may not bill patients for additional amounts
– difference must be entered into system as write-off
– amt. is determined by HHS & XIX of SS Act
PCP’s Medicaid PIN
Date PCP contracted the referring provider
Reason for referral
Patient’s Medicaid ID number
Patient’s date of birth
payer of Last Resort
Medicare-Medicaid Crossover Claims
Unacceptable Billing Practices
Medicaid claim completion
HIPAA Claims (837 & 835)
CMS-1500 Paper Claims
– Fiscal Intermediary (private ins. co)
– Department of Health and Human Services
– County welfare agency
Medical offices have specific claim filing & completion requirement forms from agency who processes claims.
ICD-9-CM is used for diagnoses.
-Billing for not provided services, or more than once
-submitting indiv. claims that are part of global procedure
-submitting claim for indiv. provider when a group practice or clinic performs services.
relevant supporting documentation
note explaining why the claim should be reconsidered
Highest level for Medicaid appeal is Appellate court
-using HIPAA 837 claim.
-In some situations the paper claim CMS-1500 may be used
-State specific form
Y= FMP involvement
N = FMP no involvement
N = services are not result of screening referral
those desiring it must enroll, coverage is not automatic
Beneficiaries pay a monthy premium based on SS benefit rates.
Subject to annual deductible and coinsurance
2. Medicare Advantage Plans
Must be verbally communicated to beneficiary.
patient must review and sign it.
not required in Emergency situation.
2. Body (Blanks D-F)
3. Options Box (Blank G)
4.Additional Informaiton (Blank H)
5. Signature Bos (Blanks I-J)
– Responsible for informing patients when services will not, or a re not likely to be, paid by the program
– Must comply with numerous billing rules such as global periods.
– Patient Name
– ID Number
E. Reason Medicare May Not pay (for this test for your condition, denied as too frequent a service, experimental or research use tests)
F. Estimated cost
1. Receive items/services & requires a claim be submitted
2. receive items/services by paying out of pocket; no claim filed & Medicare not billed
3. Beneficiary opts out of receiving care
May only choose 1 option
nonPARs who accept assignment and
nonPARs who do not accept assignment.
– patients responsible for annual deductible
2. Medicare private fee-for-service plans
3. Medical Savings Accounts (MSAs) – Medicare health Savings Account program
POS = Point of Service (independent practices assoc)
PPOs = in network, but may also go out of network
SNPs = special Needs Plans
RFBs = Religious Fraternal Benifits Plans
– coverage varies, but all provide coverage for patient deductibles and coinsurance
– Some also cover excluded services such as prescription drugs and limited preventative care.
– from provider
– to the MAC
– back to provider
CCi Edits & Global Surgical Packages
Consultation Codes; Noncompliant billing
Physician Quality Reporting Initiative (PQRI)
MR – Medical Review Program
RAC program – Recovery Audit Contractor Initiative
MPFS lists all the CPT/HCPCS codes and includes a column labeled GLOBAL PERIOD containing one of the indicators (000, 010, 090, MMM, XXX, YYY, ZZZ)
– Probe review- checking 20-40 claims for errors
– Prepayment review – form of probation after errors are found in probe review… teaches correct billing procedure
– Postpayment review – another form of probation instead of prepayment review…. targets overbilling
RAC program is in all 50 states
– Paper claims cannot be paid before the 29th day after receipt of the claim, according to CMS guidelines
Assumed Care Date / Relinquished Care Date
– Federal Employees Health Benefits Program
– Self-Funded Health Plans
– Individual Health Plans
– Insurance coverage is purchased from an insurance carrier or managed care organization
– Group health plans are subject to state laws for coverage and payment.
– They often hire third-party administrators and have administrative services only contracts for tasks such as subscriber enrollment and claim processing
– Plans are controlled by federal ERISA law rather than by state law.
– Decide on basic plan coverage and optional riders; eligibility requirements; and premiums and deductibles.
– The federal COBRA and HIPAA laws must be observed by the plans to ensure portability and coverage as required.
HSA Health savings accounts
HRA Health Reimbursement account
CIGNA Health Care
– BCBS offers the BlueCard program and the Flixible Blue plan
2. Contract purpose and covered medical services
3. Physician’s responsibilities
4. managed care plan obligations
5. Compensation and billing guidelines
2. In health maintenance organizations (HMO’s) and Point of Service (POS) Plans
3. Indemnity Plans
1. a high-deductible health plan and
2. one or more tax-preferred savings accounts that the consumer/ policyholder directs.
A savings account created by an individual. The maximum amount that can be saved each yr. is set by the IRS.
– Getting Billing Information
– Billing for No-Shows
– Collecting Copayments
– Billing and Surgical procedures
a number of states prohibit silent PPO’s and state insurance commissions in other state may be considering such laws
– list key info. about each contracted pland
– provide a shortucut reference for billing & reimbursement process
– include info. about collecting payments at time of service & completing caims
HSA, HRA, FSA,
2. Patient uses money in account to pay for quilified medical services
3. Total deductible must be met before any benefits are paid by HDHP
4. Once deductible is met, HDHP covers a portion of the benefits
– Managed care org’s business history, accreditation standing and licensure status are reviewd
– Contract purpose & covered medical service
– Physician’s responsibilitie
– Managed care plan obligations
– Compensation & billing guidelines
– acceptance of plan members
– quality assurance/utilization review
– Other provisions – HIPAA privacy policies, plan protocols