Government Carriers/Medicare, Mediaid, TRICARD

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MEDICAID	Medicaid is a health insurance program for low-income individuals and families that cannot afford healthcare costs.
MEDICAID ELIGIBILITY	1. US Citizen 2. Proof of eligible immigration 3. SSN 4. TANF 5. Children under the age of 6 --family FPL 6. Pregnant women -- FPL 7. SSI 8. Foster Care or adoption assistance 9. Fall under protected group 10. Children born after 1983, are under 19 and in families w/ income at or below FPL
MEDICAID BENEFITS	State Medicaid agencies can choose to provide other optional benefits through the state Medicaid program. Medicaid programs must provide the mandatory benefits to eligible individuals to receive matching federal funds known as Federal Medical Assistance Percentage (FMAP).
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)	The EPSDT benefit provides comprehensive and preventive healthcare services for enrolled children under the age of 21.
Prior Authorization	The Clinical Prior Authorization Program was implemented to manage drug classes that require additional monitoring, ensuring drugs are being prescribed for the right patients and the appropriate reasons, and monitor drug expenditures.
Medicaid Claims Filing Requirements	Medicaid cannot make payments to recipients, so the provider that performed the service is required to file a claim and agree to accept assignment (accept the allowed amount as payment in full). Some states require providers to submit claims electronically, unless a claim requires attachments, while others allow providers to choose how they wish to submit. Timely filing requirements will also vary from state to state. Medicaid is always considered the payer of last resort.
Medicaid Claims Completion Guidelines	Claims for Medicaid services are submitted on a CMS-1500 form using the specific code sets adopted by HIPAA. This includes HCPCS Level II codes, CPT® codes, ICD-10-CM codes, and National Drug Codes (NDC).
Common Denials for Medicaid Claims	1. Recipient not eligible 2. Recipient covered by another payer 3. Frequency of service exceeded 5. Diagnosis invalid for date of service
Medigap	Medigap refers to a Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover, like deductibles, copayments, and coinsurances. Some policies may offer coverage for services not covered by Medicare, like coverage if a patient is injured or becomes ill while traveling outside the United States. Medigap policies usually don’t cover prescription drugs, long-term care, vision care, dental care, hearing aids, eyeglasses, or private duty nurses. Patients pay a separate premium to the Medigap insurer
Medigap Claims Processing	Information and instructions on processing of Medigap claims can be found in the Medicare Claims Processing Manual, chapter 28—Coordination with Medigap, Medicaid, and other complimentary insurers. If the Medicare beneficiary has authorized payment to be made to the physician or provider, Medicare must transfer the Medicare claims information to the Medigap insurer. This is indicated by the signature on file notice in box 13 on the CMS-1500 form. A claim in which a beneficiary assigns their benefits under a Medigap policy to a participating physician, provider, or supplier is called a mandated Medigap transfer. The transfer of the claims information to the Medigap insurance is called cross-over
Cross-over	The transfer of claims information to Medigap insurance
Medigap Transfer	A claim in which a beneficiary assigns their benefits under a Medigap policy to a participating physician, provider, or supplier
EOMB	Explanation of Medicare Benefits, sent when items in block 9 is completed and accurate and the physician is a participating provider. MA18 The claim information is also being forwarded to the patient’s supplemental insurer. Send any questions regarding supplemental benefits to them MA19 Information was never sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer.
COBRA	Coordinaton of Benefits Agreement
TRICARE (FORMERLY CHAMPUS)	the Department of Defense healthcare program for military families and retirees.
CHAMPVA (THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERANS AFFAIRS)	healthcare program in which the Department of Veterans Affairs covers spouses, widows and widowers, and the children of a veteran who is rated permanently and totally disabled due to a service-connected disability, died of a service-connected disability, or died on active service and the dependents are not eligible for TRICARE. In specific instances, veterans may themselves qualify for CHAMPVA, also
DEPARTMENT OF DEFENSE DEFINITION OF CASE MANAGEMENT	CASE MANAGEMENT AS A COLLABORATIVE PROCESS UNDER THE POPULATION HEALTH CONTINUUM WHICH ASSESSES, PLANS, IMPLEMENTS, COORDINATES, MONITORS, AND EVALUATES OPTIONS AND SERVICES TO MEET AN INDIVIDUAL'S HEALTH THROUGH COMMUNICATION AND AVAILABLE RESOURCES TO PROMOTE QUALIFY COST-EFFECTIVE OUTCOMES.
TRICARE Prime	MTFs are the principal source of healthcare, civilian clinics may be used in some cases. All active duty service members are eligible for TRICARE Prime. Managed care option Enrollees choose a primary care manager (PCM) who coordinates patient care, maintains patient health records, and refers patients to specialists, when necessary. No annual deductible No annual enrollment fee for active duty members and their families.
TRICARE Extra	Preferred Provider Option No enrollment requirement No annual fee Deductible and coinsurance for outpatient care. Not required to have a primary care manager or request a referral to see a specialist Not available to active duty service members Co-payments are 5 percent lower than TRICARE standard Physician or provider is responsible for filing claims
TRICARE Standard	A fee-for-service option that allows enrollees the most choices TRICARE is the authorized provider Providers are not required to participate in the TRICARE network but must be certified as an authorized provider by the manager care support contractor (MCSC) in the region they are in. No enrollment requirement or annual fee There is a deductible and coinsurance for outpatient care Not available to active duty service members Co-insurance is 20 percent of allowed charges for covered services Enrollees have to file their own claims
CHAMPVA	fee-for-service insurance enrollees may see any provider they choose and do not need a PCM There is a deductible and coinsurance for care You cannot be eligible for TRICARE Pays 75% of the allowable amount for covered outpatient services.
Beneficiary Counseling and Assistance Coordinators (BCACs)	Available to answer questions to help the member solve healthcare related problems,
CAC	TRICARE Common Access Cards
DBN	DoD ID Benefits number -- 11 digits when verifying the cardbearer's TRICARE eligibiity and filing claims
DoD ID	10-dg9t number on the ID card and it is not used for eligibility or filing claims
COMMON DENIALS FOR TRICARE	1. Not eligible on DEERS 2. No authorization 3. Not medically necessary
TRICARE Appeals	TRICARE allows for a review of a claim without opening an appeal. If there is a concern about how a claim is processed, the provider can request a claim review by sending a letter with the reason for requesting the claim review, a copy of the claim, the remittance advice, supporting medical records, and any new information needed for the review.
Common Reasons for a TRICARE claim review	Allowed amount disputes l Charges denied as “Included in a paid service” l Charges denied as “Requested information not received” l Claim denied as “Provider not authorized” l Claim Check denials l Coding issues l Cost-share and deductible issues l Eligibility denials l Other health insurance issues l Penalties for no authorization l Point-of-service disputes (Exception: Point-of-service for emergency services is appealable.) l Third party liability issues l Timely filing limit denials l Wrong procedure code
Which charges are denied through TRICARE	Only charges denied as services not covered by TRICARE or not medically necessary can be appealed through TRICARE.
What should be included on the TRICARE appeal	the patient’s name, address, phone number, and sponsor’s Social Security number l printed name of the person submitting the appeal and the relationship to the patient l the reason you are disputing the denial l a copy of the EOB or provider remittance l additional documents supporting the appeal
RBRVS/RVU Concepts	It incorporates three components of physician services—physician work, practice expense (PE), and professional liability insurance (PLI). The physician work component comprises about 50.9 percent of the total RVU, the PE comprises about 44.8 percent of the total RVU, and the PLI comprises about 4.3 percent of the total RVU
RVU	Relative Value Unit is assigned to each of the work, PE and PLI components The RBRVS system applies to CPT® codes, so the work RVU + PE RVU + PLI RVU = Total RVU. The total RVU is multiplied by a conversion factor (CF) to obtain the reimbursement for that code. The CF is the dollar amount by which each CPT® code’s total RVU value is multiplied to obtain the reimbursement for a given service. The CF is updated annually by CMS. The 2017 CF is $35.8887
GAF (GPCI)	Geographic Adjustment Factor (Geographic Practice Code Index) applied for local code differences for the components (work, practice expense, and PLI) nationally
Status Codes	reflects Medicare coverage and payment policy. It can indicate if a service is payable, noncovered, bundled into another service, etc.
Status Code A	Active Code (Payable under the physician fee schedule) PFS
Status Code B	Bundled code (Payment for covered services that are always bundled into payment for other services)
Status Code C	Carrier -priced code (CMS contractor establishes RVUs and payment amounts for these services)
Status Code E	Excluded by regulation (No payment made under PFS)
Status Code I	Not valid for Medicare purposes (Medicare uses another code for reporting of any payment of these services)
Status Code M	Measurement codes (Indicates PQRS code. No payment and no RVUs attached with these codes).
Status Code N	Non-Covered service (No Medicare payment is made for these services. RVUs may be shown, but they are not used by Medicare.
Status Code P	Bundled/Excluded codes (No separate payment is made and no RVUs attached with these codes.
Status Code Q	Therapy functional information code (Used for reporting purposes. No separate payment is made for these services)
Status Code R	Restricted coverage (Special coverage instructions apply. If no RVUs are shown, the service is carrier-priced)
Status Code T	Paid as only service (These services are only paid if there are no other services payable under the PFS billed on the same day by the same provider)
Status Code X	Statutory exclusion (These codes represent items or services that are not within the statutory definition of a physician service, so no payment may be made under the PFS)
PC/TC Indicator	Indicates a service's technical and professional component breakdown.
PC/TC Indicator 0	Physician Service Codes
PC/TC Indicator 1	Diagnostic tests and radiology services
PC/TC Indicator 2	Professional component onl codes
PC/TC Indicator 3	Technical Component only codes
PC/TC Indicator 4	Global test only codes
PC/TC Indicator 5	Incident-to codes
PC/TC Indicator 6	Laboratory physician interpretation codes
PC/TC Indicator 7	Private practice therapist's service
PC/TC Indicator 8	Physician interpretation codes
PC/TC Indicator 9	Not applicable
Global Surgery Indicators	this field shows hoa many global days, if any, are applicable to the code.
Global Surgery Indicators 000	000 = Global surgery period includes day of procedure only (Endoscopic or minor procedures on same day are included)
Global Surgery Indicators 010	010 = Global surgery period includes day of and 10 days after surgery (Minor procedures with pre-op on day of procedure and a 10 day post-operative period all included in the listed RVUs for the code)
Global Surgery Indicators 090	090 = Global surgery period includes day before, day of, and 90 days after surgical procedure (Major surgery with a 1 day pre-operative period and a 90-day post-operative period included in the listed RVUs for the code
Global Surgery Indicators MMM	Global surgery period does not apply; used for maternity codes
Global Surgery Indicators XXX	Global surgery period does not apply
Global Surgery Indicators YYY	Global surgery period determined by carrier
Global Surgery Indicators ZZZ	Code falls within global surgery period for another service (Service always included in the global period of the other service)
Three fields following the global surgery days field breakdown	pre-operative post-operative intra-operative
Multiple procedure	indicates the applicable payment adjustment rule for multiple procedures
Multiple procedure 0	no payment adjustment rules for multiple procedures apply
Multiple procedure 1	Standard payment adjustment rules in effect before January 1, 1996 for multiple procedures apply (100 percent for the first procedure, 50 percent for the second, 25 percent for the third and any additional procedures)
Multiple procedure 2	Standard payment adjustment rules for multiple procedures apply (100 percent for the first, 50 percent for all additional procedures)
DEERS	Defense Enrollment Eligibility Reporting System (Database)
DoD Benefits Number (DBN)	11 digit number for verifying the cardbearer's TRICARE eligibility and filing claims.
DoD ID number	I0 digit number on the ID card and is not used for eligibility or filing clais
Two types of TRICARE providers	network providers and non network providers
Multiple procedure 3	special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (another code with the same base endoscopic procedure code)
Multiple Procedure 4	Special rules for the technical component of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family 100 for the first procedure, 50% for each additional procedure.
Multiple Procedure 5	Subject to 20 percent of the practice expense component for certain therapy services (25 percent reduction if an institutional setting)
Multiple Procedure	If a healthcare provider performs multiple procedures during a single patient encounter, Medicare and many commercial insurers will pay the full price for only the highest valued procedure.
The Clinical Prior Authorization Program	implemented to manage drug classes that require additional monitoring, ensuring drugs are being prescribed for the right patients and the appropriate reasons, and monitor drug expenditures.
Multiple Procedure 6	Special rules for the TC of multiple diagnostic cardiovascular services. Full payment for the service with the highest payment under the MPFS. Payment of 75 percent% for subsequent services by the same physician, or physicians of the same group, to the same patient on the same day
Multiple Procedure 7	Special rules for the TC of multiple ophthalmology services. Full payment for the service with the highest payment under the MPFS. Payment of 80 percent % for subsequent services by the same physician, or physicians of the same group, to the same patient on the same day.
Technical Component 9	Concept does not apply
Bilateral surgery	indicates services subject to payment adjustment for bilateral procedures.
Bilateral surgery 0	150 percent payment adjustment for bilateral procedures does not apply . The bilateral adjustment is inappropriate for these codes because of physiology or anatomy or because the code description specifically states the procedure is unilateral and there is an existing code for a bilateral procedure.
Medigap	Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that original Medicare does not cover.
Bilateral surgery 1	150 percent payment adjustment for bilateral procedures applies. Payment is based on 150 percent of the fee schedule amount of the single code
Bilateral surgery 2	150 percent payment adjustment for bilateral procedures does not apply
Bilateral surgery 3	The usual payment adjustment for bilateral procedures does not apply. Payment is based on 100 percent of the fee schedule amount for each side. This is generally radiology procedures or diagnostic tests which are not subject to the special payment rules for other bilateral surgeries.
Bilateral surgery 9	Concept does not apply
Assistant at Surgery	indicates services where an assistant at surgery is never paid for per the Medicare Claims Manual
Assistant at Surgery 0	Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity
Assistant at Surgery 1	Statutory payment restriction for assistants at surgery applies to this procedure. Assistant surgery may not be paid.
Assistant at Surgery 2	Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.
Assistant at Surgery 9	Concept does not apply.
Co-surgeons	indicates services for which two surgeons, each in a different specialty, may be paid.
Co-surgeons 0	Co-surgeons not permitted for this procedure
Co-surgeons 1	Co-surgeons cannot be paid. but supporting documentation is required to establish the medical necessity of two surgeons for this procedure.
Co-surgeons 2	Co-surgeons permitted and no-documentation required if the two-specialty requirement is met
Co-surgeons 9	Concept does not apply
Team Surgery	indicates surgeons for which team surgeons may be paid
Team surgeons 0	Team surgeons not permitted for this procedure
Team surgeons 1	Team surgeons could not be paid, but supporting documentation is required to establish medical necessity of a team.
Team surgeons 2	Team surgeons permitted. These are paid by report.
Team surgeons 9	Concept does not apply.
Endoscopic base code field	The last field in the global surgery indicators that identifies endoscopic base code for any code with a multiple surgery indicator of 3
Accept Assignment	A provider agrees to accept the amount allowed by the insurance company as payment in full
Advance Beneficiary Notice	A notice Medicare requires forhealthcare providers to issue to Medicare patients as a definite way to make them aware of the fact that Medicare may not pay for certain services or tests prior to having the services or tests performed in an outpatient setting
Civilian Health and Medical Program of tf the Department of Veteran Affairs CHAMPVA	Healthcare program in which the Departmentof Veterans Affairs covers spouses, widows(ers), and the children of a veteran who is rated permanently and totally disabled due to a service connected disability, died of a service connected disability, or died on active service and the dependents are not eligible for TRICARE
Crossover Claim	The transfer of processed claim data fromMedicare operatons to Medicaid (or state) agencies and Medigap insurers
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)	Medicaid benefit that provides comprehensive and preventive healthcare services for enrolled children under the age of 21.
Medigap	Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that Original Medicare does not cover.
National Provider Identifier (NPI)	A unique 10-digit identification number required by HIPAA for all healthcare providers in the United States. Providers must use their NPI to identify themselves in all HIPAA transactions.
Non-Participating Provider	A physician, hospital or other healthcare entity that does not have a participating agreement with an insurance plan's network.
Participating Provider	A physician, hospital, or other health-care entity that is part of an insurance plan's network.
Relative Value Unit	Measure of value used by Medicare in the resource based relative value system
Resourced Based Relative Value System	A systemof payments to physicians for treating Medicare patients that takes into account th work done by the physicians, malpractice insurance, and practice expenses including staff salaries overhead, supplies, and equipment
TRICARE	The Department of Defense healthcare program for military families and retirees.
Medicare Eligibility	Most people 65 and older People with certain disabilities People with ESRD
Medicare Parts	4 parts Part A (Hospitals) Part B (Physician Visits) Part C (Managed Care) Part D (Prescription)
Medicare -- Contractual Options	Participating Providers Non-Participating Providers

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Government Carriers/Medicare, Mediaid, TRICARD

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