Deck 13: Medicaid Medical Billing

Question 1

In some states, a spend-down program requires that individuals must spend a portion of their income or resources each month on medical expenses before:

A) Medicare begins paying for services.
B) Medicaid begins paying for services.
C) a deductible is paid.
D) a coinsurance amount applies.

Answer 1

Medicaid begins paying for services.

Question 2

Under the Welfare Reform Bill, mandatory covered services for immigrants include:

A) prenatal care.
B) well-child checkups.
C) emergency services.
D) preventive services.

Answer 2

preventive services.

Question 3

Mandatory Medicaid services do not include which of the following?

A) Inpatient hospital services
B) Nurse-midwife services
C) Optometrist services
D) Vaccines for children

Answer 3

Optometrist services

Question 4

Mandatory Medicaid services include coverage for:

A) early and periodic screening, diagnostic, and treatment services for children younger than age 21.
B) physical therapy services.
C) prescribed drugs.
D) transportation services.

Question 5

The goal of the Children's Health Insurance Program Reauthorization Act (CHIPRA) is to expand Medicaid eligibility to more:

A) children with disabilities.
B) working individuals without insurance.
C) children without health insurance.
D) immigrants.

Question 6

A physician may bill a Medicaid patient for services if the:

A) service was not medically necessary.
B) patient signed an advance beneficiary notice (ABN).
C) claim was not filed in a timely manner.
D) necessary preauthorization was not obtained.

Question 7

Medicaid participating hospitals and other inpatient facilities file claims electronically using the:

A) UB-04 claim form.
B) CMS-1500 claim form.
C) Medicaid claim form.
D) Title XIX claim form.

Question 8

Which types of nominal cost sharing can states require of most Medicaid beneficiaries?

A) Deductibles
B) Coinsurance
C) Copayments
D) all of the above

Question 9

Eligibility for Temporary Assistance for Needy Families (TANF) is determined by the:

A) city.
B) county.
C) state.
D) nation.

Question 10

Groups included as eligible for Medicaid include:

A) the categorically needy.
B) the medically needy.
C) special groups.
D) all of the above.

Question 11

The early and periodic screening, diagnosis, and treatment (EPSDT) program includes coverage for children younger than age:

A) 2.
B) 6.
C) 19.
D) 21.

Question 12

The organization responsible for determining the type, amount, and scope of services covered by Medicaid is:

A) the Centers for Medicare and Medicaid Services (CMS).
B) the federal government.
C) each state government.
D) contracted insurance carriers.

Question 13

The early and periodic screening, diagnosis, and treatment (EPSDT) program provides coverage for:

A) early and preventative services for dependency treatment.
B) easy periodic screening for dependents' treatment.
C) early and periodic screening, diagnosis, and treatment.
D) early and preventative services for diagnosis and treatment.

Question 14

To qualify for federal matching funds for the medically needy, states must include coverage for:

A) pregnant women.
B) the elderly.
C) the blind.
D) the disabled.

Question 15

The largest funding for healthcare for America's low-income individuals comes from:

A) Medicare.
B) Medicaid.
C) private insurance.
D) individuals.

Question 16

Care provided under the PACE program can be rendered in:

A) nursing homes.
B) hospitals.
C) the patient's home.
D) all of the above.

Question 17

Medicaid is health insurance coverage for:

A) the aged.
B) the disabled.
C) low-income individuals.
D) those with end-stage renal disease (ESRD).

Question 18

States will get federal matching funds for categorically needy groups that include all of the following EXCEPT:

A) families who meet Eligibility for Temporary Assistance for Needy Families (TANF, formerly AFDC) eligibility requirements.
B) children ages 6 to 19 in families with income up to 100% of the federal poverty level.
C) caretakers of children younger than age 18.
D) individuals age 65 and older.

Question 19

Medicaid is paid for by:

A) the local government.
B) the federal government.
C) the state government.
D) the federal and state government.

Question 20

Optional Medicaid services that are eligible for federal matching funds include all of the following EXCEPT:

A) transportation services.
B) rehabilitation services.
C) acupuncture for pain relief.
D) optometrist services and eyeglasses.

Question 21

Due to the Affordable Care Act of 2010, Medicaid expenditures are expected to increase by how much over earlier projections?

A) 3%
B) 5%
C) 8%
D) 10%

Question 22

If an individual is covered by both Medicaid and Medicare:

A) Medicare is always primary.
B) Medicaid is always primary.
C) Medicaid is primary only if the individual is younger than 65.
D) Medicare is primary only if the individual is younger than 65.

Question 23

Special groups that may be eligible for Medicaid include all the following EXCEPT:

A) immigrants.
B) families that need temporary assistance.
C) disabled adults.
D) children with disabilities.

Question 24

The federal government matches state expenditures for:

A) mandatory services.
B) state optional services.
C) administrative costs.
D) all of the above.

Question 25

Two managed care models implemented in state Medicaid programs include:

A) HMOs and POS.
B) HMOs and PCCM.
C) POS and PCCM.
D) PPOs and POS.

Question 26

In a Medicaid managed care plan, the role of the care coordinator is to do all the following EXCEPT:

A) provide community-based services.
B) coordinate all acute and long-term care.
C) develop an individual plan of care.
D) enroll beneficiaries in appropriate plans.

Question 27

The total number of individuals enrolled in Medicaid and CHIP in January 2015 was nearly:

A) 20 million.
B) 40 million.
C) 50 million.
D) 70 million.

Question 28

States may pay for Medicaid services on a fee-for-service basis or:

A) based on the Medicare fee schedule.
B) through contracts with managed care organizations.
C) using a scale based on the beneficiary's annual income.
D) through a per-diem rate.

Question 29

Those Medicaid beneficiaries who are excluded from cost-sharing provisions include:

A) the blind.
B) the elderly.
C) pregnant women.
D) the disabled.

Question 30

The goal of Medicaid managed care is:

A) to increase access to care.
B) to reduce service fragmentation.
C) to reduce costs.
D) all of the above.

Question 31

Appeals of denied claims or claim adjustments must be filed within:

A) 95 days from the date of service.
B) 95 days from the date of disposition.
C) 180 days from the date of disposition.
D) 180 days from the date of service.

Question 32

What must states file with CMS to request permission to make changes in the design and implementation of their Medicaid programs?

A) Payment request
B) Authorization request
C) Waiver request
D) Certification request

Question 33

A copayment may NOT be collected from a Medicaid patient for:

A) hospital services.
B) family planning services.
C) physician office visits.
D) preventive care services.

Question 34

If a Medicaid patient is on restricted status when eligibility is verified, the patient is required to:

A) receive only certain services.
B) receive services only from a specific provider.
C) obtain authorization for all services.
D) obtain services only in cases of an emergency.

Question 35

The medical office specialist should verify a patient's Medicaid eligibility:

A) at every visit.
B) twice a month.
C) every 2 months.
D) every 6 months.

Question 36

To be considered for payment, Medicaid claims for inpatient services must be received within:

A) 65 days from the discharge date.
B) 95 days from the discharge date.
C) 180 days from the date of service.
D) 1 year from the date of service.

Question 37

Under a primary care case management (PCCM) arrangement, primary care physicians are paid on a:

A) monthly capitation basis.
B) monthly capitation basis plus a case-management fee.
C) fee-for-service basis.
D) fee-for-service basis plus a case-management fee.

Question 38

The federal government reimburses states for the cost of services provided by Indian Health Service facilities at a rate of:

A) 0%.
B) 50%.
C) 75%.
D) 100%.

Question 39

The abbreviation PCCM used in regard to Medicaid managed care plans stands for:

A) per case care management.
B) preventive care case management.
C) primary care case management.
D) primary coverage and care management.

Question 40

In regard to Medicaid managed care, what does the term medical home mean?

A) The PCP serves as the "medical home" by coordinating care and controlling costs.
B) The "medical home" is the city or town in which the beneficiary receives services.
C) The "medical home" is any type of inpatient facility, to which a beneficiary has been admitted.
D) The beneficiary's primary place of residence is the "medical home."

Question 41

A person eligible for Medicaid in one state is automatically eligible in all other states.

Question 42

Although not recommended, hospitals reimbursed according to diagnostic-related group (DRG) payment methodology may submit an interim claim if the client has been in a facility for:

A) 10 days or longer.
B) 30 days or longer.
C) 60 days or longer.
D) 90 days or longer.

Question 43

As a result of the Welfare Reform Bill, legal resident aliens who entered the United States after 1996 are NOT eligible for Medicaid for 8 years.

Question 44

Form locator 22 indicates:

A) Patient's relationship to insured.
B) Medicaid Resubmission Code.
C) EPSDT Family Plan.
D) Accept Assignment Code.

Question 45

Programs of All-Inclusive Care for the Elderly (PACE) providers agree to make all services available to beneficiaries without any cost-sharing requirements.

Question 46

In form locator 24H EPSTD Family Plan, which code is used when a patient refused a referral?

A) AV
B) ST
C) NU
D) PR

Question 47

For a dependent 6-year-old child, form locator 6 should indicate that the patient's relationship to the insured is:

A) self.
B) child.
C) dependent.
D) other.

Question 48

To verify a patient's eligibility of Medicaid, the medical office specialist can do all the following EXCEPT:

A) scan the patient's Medicaid card.
B) enter the Medicaid number on the Medicaid website.
C) check the website for eligibility from 3 months past to current data.
D) call the Department of Human Services.

Question 49

States determine the amount and duration of Medicaid services and can set limits based on medical diagnoses or conditions.

Question 50

The code ST used in form locator 24H in regard to early and periodic screening, diagnosis, and treatment (EPSDT) services means :

A) services were not available.
B) services were available and used.
C) new services were requested.
D) services were available but not authorized.

Question 51

Physician services claims are filed using the:

A) claim UB-04 form.
B) CMS-1500 claim form.
C) UB-92 claim form.
D) Medicaid PCCM claim form.

Question 52

The code S2 used in form locator 24H in regard to early and periodic screening, diagnosis, and treatment (EPSDT) services means :

A) services were not available.
B) new services were requested.
C) the patient is currently under treatment.
D) services were available and used.

Question 53

Patients are not charged a fee for EPSDT services; however, some families do pay a premium.

Question 54

Hospitals are NOT permitted to submit interim claims for Medicaid patients while they are still hospitalized.

Question 55

If a state elects to have a medically needy Medicaid program, it must include coverage for pregnant women.

Question 56

When filing a claim for a newborn boy baby whose mother is Jane Doe, the name field of the claim form should state:

A) Newborn Male Doe.
B) Baby Boy Doe.
C) Boy Jane Doe.
D) Newborn Baby Boy.

Question 57

State legislators cannot make changes in Medicaid eligibility or services.

Question 58

If a claim is denied by Medicaid because prior authorization was NOT obtained, the physician can bill the patient for the services.

Question 59

The federal government pays for a percentage of the costs of medical services by reimbursing each state; this percentage is known as the:

A) Federal Medical Assistance Percentage (FMAP).
B) State Medical Assistance Percentage (SMAP).
C) Federal Medicaid Reimbursement Percentage (FMRP).
D) State Medicaid Reimbursement Percentage (SMRP).

Question 60

Providers participating in Medicaid must accept the Medicaid payment rate as payment in full and cannot balance-bill the patient.

Question 61

The program that provides states with grants to be spent on time-limited cash assistance to low-income families is called ________.

Question 62

The cost of Medicaid benefits has been decreasing rapidly since the 1990s.

Question 63

To be considered for payment, a denied Medicaid claim must be appealed within 60 days of the date of denial notification.

Question 64

Federal Medical Assistance Percentage is calculated ________ for each state based on a statutory formula that takes into account state per capita income with some adjustments prescribed by legislation.

Question 65

If a Medicaid patient is on restricted status, the patient is required to see a specific physician and/or to use a specific pharmacy.

Question 66

Healthcare Common Procedure Coding System (HCPCS) codes are required on both Medicaid physician and hospital claim forms.

Question 67

The category of individuals who would be eligible for Medicaid services but have too much money is known as the ________.

Question 68

Providers must resubmit a signed, completed/corrected claim with a copy of the R&S on which the denied claim appears within 180 days from the date of the R&S to be considered for payment.

Question 69

Most states provide electronic verification of Medicaid eligibility.

Question 70

Claims filed by a hospital for inpatient services must be received by Medicaid within 95 days of the discharge date.

Question 71

The form signed by a patient that states the amount and reason why a procedure is NOT covered by Medicaid is a(n) ________ notice.

Question 72

The federal government matches state expenditures for medical assistance with no set limit or cap.

Question 73

A low-income individual age 65 or older may be eligible for both Medicare and ________ health insurance coverage.

Question 74

Legal resident aliens who entered the United States after 1996 are eligible for Medicaid after ________ years.

Question 75

If a Medicaid claim was NOT filed within the required time limits because of an error or neglect on the part of the medical office staff, the physician can appeal the denial and seek payment.

Question 76

All Medicaid beneficiaries are exempt from copayments for ________ and ________ services.

Question 77

Medicaid patients enrolled in managed care plans must select a primary care provider.

Question 78

A type of noncapitated Medicaid managed care plan in which participants must select a primary care physician is known as primary care ________.

Question 79

People with Medicare and Medicaid automatically qualify (and do not need to apply) for Extra Help paying for Medicare prescription drug coverage.

Question 80

The federal-state program that provides medical benefits to specific groups of low-income people is ________.