NHA CMAA cheat sheet

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health; Part B covers outpatient and professional services.

Medicaid is jointly funded by federal and state governments; eligibility rules vary by state, and CHIP covers children in low-income families.

An HMO typically requires a primary care provider referral for specialists except emergencies; a PPO permits out-of-network care with higher cost sharing.

Birthday rule: for a dependent child covered by both parents, the plan of the parent whose birthday falls earlier in the calendar year is primary.

CMS-1500 is the professional paper claim form; UB-04 is the institutional claim form.

CPT reports procedures and services; ICD-10-CM reports diagnoses; HCPCS Level II reports supplies, drugs, and durable medical equipment.

Deductible is paid before insurer payment; coinsurance is a percentage of allowed charges after deductible; copayment is a fixed amount.

Timely filing is the payor-specific deadline for claim submission; a claim filed after that deadline can be denied.

NPI is a 10-digit provider identifier; the EIN/TIN identifies the billing tax entity on claims.

New patient visits generally require longer appointments than established patient visits because they include history and baseline data collection.

Insurance verification before the visit confirms eligibility, benefits, copayment, deductible, and referral or authorization requirements.

Check-in sequence: verify identity, update demographics and insurance, collect copayment, obtain signatures, and direct patient to waiting area.

Check-out sequence: schedule follow-up, collect balance, provide visit summary, arrange referrals, and confirm next steps.

Telephone triage: nonclinical staff route clinical questions to licensed staff; symptoms of emergency require immediate 911 direction.

Par level is the minimum stock quantity; reorder point equals usage during lead time plus safety stock.

Recall systems use tickler files, postcards, calls, or EHR alerts to remind patients when preventive or follow-up care is due.

Release of information requires a signed authorization except for treatment, payment, operations, or other legally permitted disclosures.

A no-show policy must state fees or consequences and be applied consistently within state law.

Active listening components: paraphrase, clarify, reflect feelings, and confirm understanding.

Teach-back: patient explains instructions in own words; staff corrects misunderstandings before discharge.

Limited English proficiency: use a qualified medical interpreter; avoid using minors or untrained family members except emergency situations.

SBAR = Situation, Background, Assessment, Recommendation; used for structured handoffs.

HIPAA minimum necessary: limit PHI use or disclosure to the amount reasonably needed for the purpose, except treatment disclosures.

Plain language: use short sentences, everyday words, and 3-5 key points; avoid jargon.

Conflict resolution steps: address privately, focus on behavior, use I-statements, seek shared solution.

Professional boundaries prohibit romantic relationships, personal social media contact, and inappropriate gifts with patients.

Telephone etiquette: identify facility and self, ask before placing on hold, avoid PHI on voicemail.

Medical record ownership: facility owns record; patient has right to access and copy under HIPAA with limited exceptions.

Correction rule: never erase; add dated addendum by author; retain original entry.

Retention periods vary by state and record type; follow the longer of state law and facility policy.

Valid authorization elements: patient ID, information to release, recipient, purpose, expiration, signature, right to revoke.

HIPAA breach notification: individuals generally notified within 60 days of discovery; HHS notified; media if breach affects more than 500 residents of a state.

Security safeguards: administrative, physical, and technical controls; use unique user IDs, access controls, and audit trails.

Subpoena: verify validity, consult legal/risk, release only legally required information.

Minors: parent or guardian is generally personal representative; exceptions include emancipated minors and certain sensitive services.

Audit trail records who accessed or changed EHR data and when; passwords must not be shared.