Payer Types and Policies Flashcards
6 cards from real CBCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Payer Types and Policies flashcards as text
What is TRICARE and who is eligible for it?
Answer: The health care program for active-duty service members, retirees, and their families through the Department of Defense
TRICARE is the healthcare benefit for members of the uniformed services (active duty, National Guard/Reserve, retired) and their eligible family members, administered by the Department of Defense.
What is a Medicare Administrative Contractor (MAC)?
Answer: A private company contracted by CMS to process Medicare fee-for-service claims in a specific geographic jurisdiction
MACs are private companies that serve as Medicare's claim processors in specific geographic regions (jurisdictions), handling Part A and Part B claims submission, payment, and audit functions.
What is the Federal Employees Health Benefits (FEHB) Program?
Answer: The health benefits program for federal civilian employees, retirees, and their dependents, offering a choice of health plans
FEHB is the health benefits program for federal civilian employees and retirees, offering enrollment in a choice of approved health plans (fee-for-service, HMO, HDHP/HSA) administered by OPM.
What is a self-funded (self-insured) employer health plan?
Answer: An employer that assumes financial responsibility for employee health claims rather than paying premiums to an insurance company; typically administered by a TPA
In a self-funded plan, the employer directly pays employee health claims from its own funds rather than buying insurance. A Third-Party Administrator (TPA) typically processes claims using the employer's money.
What is Workers' Compensation insurance, and how does billing differ from standard health insurance?
Answer: Insurance that covers medical treatment and lost wages for employees injured on the job or who develop work-related illnesses; billing uses separate forms and diagnosis coding specific to the injury
Workers' compensation covers medical care and lost wages for work-related injuries/illnesses. Claims are billed to the employer's WC carrier using state-specific forms, focus only on the work injury, and follow different reimbursement rules than standard health insurance.
What is a National Coverage Determination (NCD)?
Answer: A CMS policy determining whether a service, item, or procedure is covered nationally under Medicare, binding on all MACs and Medicare Advantage plans
An NCD is a national Medicare coverage policy issued by CMS that determines whether a specific medical service is covered, covered with conditions, or non-covered for all Medicare beneficiaries nationwide.