Payer-Specific Guidelines Flashcards
7 cards from real COBGC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Payer-Specific Guidelines flashcards as text
TRICARE covers which of the following maternity services for a military dependent spouse enrolled in TRICARE Prime?
Answer: Comprehensive maternity care including prenatal, delivery, and postpartum services at both military and TRICARE-network civilian facilities
TRICARE Prime covers comprehensive maternity care for enrolled military dependents at both military treatment facilities and TRICARE-authorized civilian network providers.
CHIP (Children's Health Insurance Program) primarily covers which population relevant to OB/GYN coding?
Answer: Children under age 19 in families with incomes too high for Medicaid but who cannot afford private insurance
CHIP covers uninsured children in families with incomes too high to qualify for Medicaid but who cannot afford private coverage; some states also extend CHIP to cover pregnant women through CHIP unborn child provisions.
A patient is injured in a work-related accident that causes a miscarriage. Which payer should the OB/GYN provider bill for the related treatment?
Answer: Workers' compensation insurance
When an injury or condition is work-related and covered under workers' compensation, the workers' comp carrier is the appropriate primary payer for all treatment related to that injury.
Under the ACA, health plans offered through the Marketplace (Exchange) must cover which category of OB/GYN services as essential health benefits?
Answer: Maternity and newborn care as one of the ten essential health benefit categories
The ACA requires all Marketplace plans to cover the ten essential health benefits, of which 'maternity and newborn care' is one, ensuring minimum OB coverage across all qualifying plans.
A Federally Qualified Health Center (FQHC) bills Medicare for an OB/GYN visit. How is reimbursement typically structured for FQHCs?
Answer: Under the FQHC Prospective Payment System (PPS), an all-inclusive per-visit rate
FQHCs are reimbursed by Medicare under the FQHC Prospective Payment System, which pays an all-inclusive per-visit rate rather than fee-for-service rates for individual procedures.
When a value-based contract includes a maternity bundled payment, what does the provider typically receive for an uncomplicated vaginal delivery episode?
Answer: A single predetermined payment covering all prenatal, delivery, and postpartum care for the episode
Maternity bundled payment programs provide a single episode-of-care payment covering all services from pregnancy confirmation through postpartum, incentivizing efficiency and quality over volume.
A commercial payer's contract includes a 'most favored nation' (MFN) clause. How does this affect OB/GYN billing rates?
Answer: The provider must charge this payer a rate no higher than the lowest rate it accepts from any other commercial payer
A most favored nation clause requires the provider to give this payer rates at least as low as the lowest rate offered to any other payer, preventing tiered pricing that disadvantages the contracting payer.