CRCR Unit 2 Questions and Answers Already Passed

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CRCR Unit 2 Questions and Answers Already Passed Types of Unscheduled Patients ✔✔Urgent (ED) patients, Walk-in OP, Observation patients, and newborns. Resource Coordination ✔✔The process o... f reserving rooms and/or equipment, ordering devices or supplies, and ensuring that professional staff (physicians, nurses, and/or technicians) are available for when a patient arrives. Patient Scheduling Core Concepts ✔✔Patient Identification, Requested Service, Scheduling Instructions, Review and Validation, Patient Reminders and Arrival Instructions, Order Requirements 270 Healthcare Eligibility Benefit Inquiry ✔✔Outbound inquiry from the provider to the health plan to confirm a patient's eligibility. Tricare ✔✔Healthcare program of the US Department if Defense Military Health System Indian Health Service (IHS) ✔✔Agency within the the DHHS which is responsible for providing federal health plans to Native Americans. Medicaid ✔✔Federally-aided, state-operated program to provide health and long term care coverage for low-income individuals or families Medicare ✔✔Government-sponsored program financed through taxes and general revenue funds. Managed Care Plans ✔✔Comprehensive healthcare plans that attempt to reduce costs through contractual agreements with providers and through care management initiatives. Commercial Indemnity Plans ✔✔Cover almost all services without authorization requirements. Blue Cross / Blue Shield ✔✔Nation's oldest and largest family of health benefits companies. Self-insured plans ✔✔Self funded plan where the costs of medical care are borne by the employer on a pay as you go basis. Liability coverage ✔✔An auto, home, or business insurance plan may include a medical clause that covers individual healthcare services associated with an accident or injury. Medicare Part A ✔✔Part of Medicare that covers IP stays, SNF, and Home Health Care Medicare Part B ✔✔Available to cover OP and professional service coverage, but the beneficiary must pay an additional monthly premium for coverage. Coinsurance amounts under part B change as OPPS is updated. Medicare Part C (Medicare Advantage) ✔✔Managed care plan which includes MCRPA &MCRPTB and may also include part D benefits Medicare Part D ✔✔Prescription drug coverage program. Consists of private insurance plans that are reimbursed by CMS or benefits provided to MCR beneficiaries. Beneficiaries may enroll in Part D or a Med Advantage plan (part C) which may also include a prescription drug benefit. Medicaid Billing Rules ✔✔Some persons are eligible for Medicaid only after they have incurred medical expenses that reduce their income (spend-down) to the Medicaid need standard. Medicaid is always the payer of last resort. TRICARE Billing Rules ✔✔Emergency services are always billed separately from IP claims. Timely filing is 1 year from discharge if primary, 90 days from payment by primary ins if secondary. The plan deducts a 10% penalty if prior auth is not obtained when required. TRICARE for Life ✔✔Supplement to Medicare. Only available to Medicare-eligible individuals who are also enrolled in Medicare part A and Part B benefits. Health Maintenance Organization (HMO) ✔✔Health plan that has management responsibility for providing comprehensive healthcare services on a pre-payment basis to voluntarily enrolled persons within a designated population. Preferred Provider Organization (PPO) ✔✔An arrangement whereby a third-party payer contracts with a group of medical care providers who furnish services at lower than usual fees in return for guarantees of a certain volume of patients. Exclusive Provider Organization (EPO) ✔✔A form of PPO in which a very select group of providers is chosen to provide benefits to one or a very limit number of entities usually a single employer. Point of Service Plan (POS) ✔✔Healthcare insurance plan that allows the member to select providers either in-network or out of network; beneficiaries are enrolled in an HMO but have the option to go outside of the network for an additional cost. Consumer Directed Health Plans (CDHP) ✔✔Specific set of health insurance arrangements in which individuals have a high-deductible health plan coupled with a personal health account (PHA) that they can use to pay health care expenses not covered by insurance. A High Deductible Health Plan (HDHP) is an example of a consumer directed health plan (CDHP). Medicare Advantage Plans ✔✔Medicare Part C program created by the Prescription Drug, Improvement, and Modernization Act (MMA), which replaced the Medicare + Choice Program. Medicaid HMO Plans ✔✔An HMO plan available only to patients enrolled in the state Medicaid programs medical benefits. Case Management ✔✔Internally-based hospital program and insurer health plan-based program which seeks to confirm that appropriate levels of care are provided based on the patient's condition. Discharge Planning ✔✔Managed care plans require this starts as soon as the patient is admitted. Includes determining the expected outcome of the patient's treatment so resolving special postservice needs will not delay discharge. Elements of Determining Price ✔✔Verification of the patient's insurance eligibility and benefits. Obtained most often by real-time electronic transaction with the health plan. Identification of the test or service involved. Obtain the total charges for the hospital portion of the case. "Pure" self-pay ✔✔Where the patient is uninsured and is responsible for the total cost of the healthcare service. Self-pay balance after insurance ✔✔Amounts to the cost the patient is responsible for as determined by employers and health plans and includes plan deductibles, co-insurance amounts, co-payment amounts, and any non-covered services. Financial Assistance Program (FAP) ✔✔Offered when the responsible party does not have the ability to pay and does not Medicaid assistance. [Show More]

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