Reimbursement Methodology & Policy. Florida. Rhonda Hood
Welcome to the Advocate Development Program Assessment! This is an individual open book/resource assessment, however please do not collaborate with your counterparts. There will be 25 randomized questions so please allow enough time to complete this assessment (approx 60 mins) and minimize distractions. As you move through the assessment feel free to reference:
- Quick Reference Guide: UnitedHealthcare’s Top 12 Frequently Referenced Reimbursement Policies for Commercial Health Plans
- Advocate Development Program - Reimbursement Methodology Study Guide
- The Policy in KL
- NDB
Question 1: What is your first and last name?
A hospital is contracted with DRG methodology for inpatient with a base rate of $12,000. We receive a claim for dates of service 11/1/2016-11/3/2016 that maps to DRG 462. What will the allowable be for this claim? Outline all steps taken to determine your answer.
What modifiers may be used to indicate a repeat procedure performed on the same day by the same group physician or other health care professional?
An E&I claim is received from a surgery group containing cpt codes 41100 and 41108. The place of service is 11. The group's contract rate is $624.00 for cpt 41100 and $610.00 for cpt 41108. What will the allowable be for each code? Explain how you arrived at your answer.
A physician has a primary specialty in NDB of Cardiology. Another physician under the same TIN has primary specialty of Internal Medicine and secondary specialty of Cardiology. If a claim was received from each of these physicians for the same member on the same date of service, would they be subject to the same day/same service policy? Explain your answer.
MPIN 1819313 is on fee schedule 09223, Market # 0032540. If this practice filed a claim with DOS 11/23/17 billed codes 47539 and 47540, what is the allowable for each code and which code would be reimbursed at 100% according to the Multiple Procedure policy?
Where can you find the list of codes that will receive a reduction when billed in combinaiton with each other by the Same Group Physicians and/or other Health Care Professional for the same member on the same date of service?
Regarding the Rebundling policy, what is the difference between a "definitive" source and an "interpretive" source?
On an electronic claim, How should the Present on Admission (POA) field be populated for diagnoses that are exempt from POA?
If a member calls and activates their Passport benefit the provider is paid as contracted or non contracted rate?
Medicare Outpatient Procedure Groupers can be found in the Medicare Payer Appendix. Where can you find information concerning Commercial Outpatient Surgery Groupers?
Which modifiers can appended to timed procedures/modalities to receive separate payment by different specialists (physical, occupational and speech therapy) within a multispecialty group that are reported under a single Tax ID Number (TIN)?
UnitedHealthcare will allow only the units up to the Maximum Frequency Per Day (MFD value). In some situations a physician or other health care professional may report units accurately and still exceed the established MFD value. What modifiers can be appended to a code that will allow the additional units to be considered. Is documentation required when these modifers are appended to a code?
Member is seen for physical therapy 5 times in one week. Contracted rate is $59 Per visit. Member has a $10.00 copay for each visit. What will be the calculated payment for the claim?
Medicare Outpatient Procedure Groupers can be found in the Medicare Payer Appendix. Where can you find information concerning Commercial Outpatient Surgery Groupers?
How many times will UHC reimburse timed procedure/modalities to distinguish timed procedures provided by different specialists (physical, occupational and speech therapy) within a multispecialty group that are reported under a single Tax ID Number (TIN)?
Most plans have this member accessibility which is set up by state and was created to still cover someone traveling to see relatives in a different state.
Within the Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy, How is the primary, secondary and subesequent procedures reimbursed?
What type of payment methodology is used for Outpatient Procedure Grouper (OPG) - Per Case, Per Visit or Per Unit?
What is one possible reason why a procedure code would not be reimbursable when billed with a modifier 50?
Are Present on Admission (POA) indicators required on inpatient Medicare claims, outpatient Medicare claims, or both?
A surgical group's contracted rate for cpt 35636 is $820.00. An E&I claim is received for the assistant surgeon in this group with modifier -AS. What will the allowable be for this procedure?
Per the Laboratory Services policy, which modifier indicator indicates a modifier cannot be used to bypass the edit to allow both submitted services or procedures?
Demonstrate how a provider has a per diem rate of $1214.00 when the member is inpatient for 4 days; what is the allowable per contract?
Member is scheduled to have an outpatient procedure. They are enrolled in a PPO product. Contract allows 85% of billed charges for PPO members. What is the allowable if the provider bills $2500.00?
During a single admission the Inpatient stop loss threshold was $75,000.00. The hospital will be paid a Payment Rate of 45% of Customary Charges. Total Charges were $95,000.00. What is the total charge?
A contract has a case rate for Vaginal delivery of $6579.00 for two days, with per diem payment of $1,122 for any additional days. If a member stays 3 days, what is the allowable?
A contract has a case rate for Cesarean Section of $8605.00 for three days, with a Per Diem rate of $1122.00 for any additional days. If a member stays 5 days, what is the allowable?
Medicare claim is denied for OCE 92 as indicated by remark code 5592. Where can you view the description of the OCE error?
What is the rate for a physician on fee schedule 9624, market 32540, for CPT code 99213 for date of service 2/1/2017?
According to the Anesthesia Policy, UHC allows for separate reimbursement of Moderate Sedation services when reported by the same physician reporting diagnostic or therapeutic procedures with which codes? .
Will Individual laboratory codes which together make up a laboratory panel code be combined and reimbursed as the more comprehensive panel code?
Per the Maximum Frequency Per Day policy, may a provider use a modifier to support additional units for codes where the CMS MAI value is "2"?
The professional component is represented by which modifier? The technical component is represented by which modifier?
What should be reported to indicate a separately identifiable service was provided on the same day when reported by providers with the same specialty and TIN.
A provider on fee schedule 71907/Market # 0032540, bills an anesthesia claim with 120 minutes of anesthesia. How many Time Units will be used in this claim's reimbursement calculation?
MPIN 1219028, Market # 0032540 is on fees schedule # 78689 bills codes 66984 with a 50 modifier and 1 unit, Date of service 8/30/17. What is the providers allowable? Note, this CPT code is subject to the Multiple Procedure policy.
Member received services by a private duty nurse. The contract says for each 15 minute increment = 1 unit at $13.50. The nurse spent 45 minutes with the member. How many unit does the provider bill for and what is their reimbursement?
Do E&I physician reimbursement schedules typically reflect the same % of CMS RBRVS for all service types?
Where should you direct a provider who is looking for a specific C&S reimbursment or medical policy?
Where should you direct an internal customer and/or peer who is looking for a specific C&S reimbursement policy?
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