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Assignment of benefits

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is the transfer of the patient's legal right to collect benefits for medical expenses to the provider of those services, authorizing the payment to be sent directly to the provider.

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audit

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the process of examining claims for accuracy and completeness before submitting the claims is called, , which can be performed manually or electronically with computer billing software.

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clean claims

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are insurance claim forms that have been completed correctly and can be processed and paid promptly if they meet the restrictions on covered services and blocks.

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audit trail

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Often referred to when tracking medical services used by patients or researching claims, is the path left by a transaction when it has been completed.

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clearinghouse

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a centralized facility to which insurance claims are transmitted, a separates, checks, and redistributes claims electronically to various insurance carriers.

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direct billing

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a method of electronic claims submission in which computer software allows a provider to submit an insurance claim directly to an insurance carrier for payment

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dirty claims

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claims that contain errors or omissions that must be corrected so that the claims can be resubmitted to an insurance carrier to obtain reimbursement .

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electronic claims

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claims that are submitted to insurance processing facilities using a computerized medium, such as direct data entry, direct wire, dial-in telephone digital fax, or personal computer download or upload.

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Electronic data interchange

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The transfer of data back and forth between two or more entities using an electronic medium

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Electronic or digital signature

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a mark that is accepted as proof of approval of or responsibility for the content of an electronic document.

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Employer identification Number

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The number used by the Internal Revenue Service to identify a business or an individual functioning as a business entity for income tax reporting .

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Incomplete claim

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A claim that is missing information and is returned to the provider for correction and resubmission, or sometimes and invalid claim.

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Intelligent Character Recognition

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The electronic scanning of printed blocks as images and the use of special software to recognize these images as ASCII text for uploading into a computer database

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National Provider Identifier

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The term for the acronym NPI

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Provider identification Number

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the term for the acronym PIN

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Unique Provider Identification Number

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the term for the acronym UPIN

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Paper claims

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Hard copies of insurance claims that have been completed and sent by surface mail

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Provider

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Any company, individual, or group that provides medical, diagnostic, or treatment services to a patient is considered

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Provider Identification Number

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A number assigned to a provider by a carrier for use in the submission of claims .

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Rejected claim

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claims that have been returned unpaid to the provider for clarification of questions and that must be corrected before resubmission

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CMS 1500 health insurance claim form

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The universal claim form was developed by the Health care Financing administration [now known as the centers for medicare and medicaid services and approved by the american medical association for use in subitting all government sponsored claims. it now is also known as

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hard copy (paper) or electronically

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a medical assistant may submit insurance claims to a third-party payer or an insurance carrier in one of two ways

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Advantage of electronic submission of insurance claims

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They are received in half the time. they catch errors and send them back

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33

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a cms-1500 claim form has_ blocks or items.

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3 section

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the blocks are divided _

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Section 1

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carrier Blcok

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Section 2

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patient/ insured section

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section 3

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physician/ supplier section

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self

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indicates that the patient is the insured

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spouse

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indicates that the patient is married to the insured

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child

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means that the patient is the insureds minor dependent

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other

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May mean that the patient is an employee, that workers compensation is the insurer, or that the patient is a ward or other dependent as defined by the insureds plan

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Primary insurance

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Blocks 11 a-d

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secondary insurance

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blocks 9 a-d

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Referring Physician

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A physician who requests an item or service for the beneficiary for which payment may be made.

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Ordering physician

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A physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient.

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no more than 4

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when entering the appropriate diagnosis or ICD-9-CM code or codes, what is the maximum number of codes that should be used on one claim form

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UPIN

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A number assigned by fiscal intermediaries to identify providers on claims for services

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Universal claim form

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The form developed by the Health Care Financing Administration (HCFA; now the centers for medicare and medicaid service [CMS] and approved by the american medical association (AMA) for use in substitution all government-sponsored claims. also known as the cms-1500 health insurance claim form

Kinns chapter 21

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