question

clean claim

answer

A claim (paper or electronic) was submitted within the program or policy time limit and contains all necessary information so that it can be processed and paid promptly. (pg. 217)

question

Clean claim means the following:

answer

1. The claim has no deficiencies and passes all electronic edits. 2. The carrier does not need to investigate outside of the carrier's operation before paying the claim. 3. The claim is investigated on a postpayment basis. A claim is not delayed BEFORE payment and may be paid. But after investigation, may be considered \"payment not due\" and refund may be requested from provider. 4. Claim subject to medical review with attached informaqtion or forwarded simultaneously with EMC records.

question

deleted claim

answer

A claim canceled, deleted, or voided by a Medicare Fiscal intermediary

question

Some reasons a claim may be deleted:

answer

CMS-1500 (08-05) or current CMS-1450 is not used, itemized charges are not provided, more than 6 line items are submitted on CMS-1500 patient's address is missing, internal clerical error was made, Certificate of Medical Necessity (CMN) not with Part B claim, or incomplete or invalid, and name of the store is not on the receipt that includes the price of the item.

question

dirty claim

answer

A claim submitted with errors, one requiring manual processing for resolving problems, or one rejected for payment.

question

durable medical equipment number

answer

Medicare providers who charge patients a few for supplies and equipment, must bill Medicare using a DME number. These claims are NOT sent to regional fiscal intermediary but to another specific location.

question

electronic claim

answer

Digital files that are not printed on paper claim forms when submitted to the payer. These claims are submitted in one of several ways: via dial-up modem (telephone line or computer modem), direct data entry, DSL (digital subscriber line) or FTP (file transfer protocol).

question

employer identification number

answer

Issued by IRS for income tax purposes, regardless if physician is in a medical group or solo practice, each physician must have own federal tax identification number (EIN) or tax identification number (TIN). Some physicians may have more than one EIN number.

question

facility provider number

answer

Number used by the performing physician to report services done at the location. Each facility (e.g., hospital, laboratory, radiology office, skille dnursing facility) is issued a facility provider number.

question

group National Provider Identifier

answer

The group NPI is used instead of the individual NPI for the performing provider who is a member of a group practice that submits claims to insurance companies under the group name.

question

Health Insurance Claim Form (CMS-1500 [08-5])

answer

Form required when submitting Medicare claims and is accepted by nearly all state Medicaid programs and private 3-rd party payers, as well as by TRICARE and workers' compensation.

question

incomplete claim

answer

Any Medicare claim missing required information. Identified to provider so that it can be RESUBMITTED on a NEW claim.

question

intelligent character recognition

answer

same as optical character recognition

question

invalid claim

answer

Any Medicare claim that contains complete, necessary information but is illogical or incorrect (e.g., listing an incorrect provider number for a referrin physician). An i

question

National Provider Identifier

answer

Lifetime 10-digit number that will replace all other numbers assigned by various health plans. Identifying system for health care providers that became effecive May 27, 2007, in connection with electronic transactions identified in HIPAA. Each health care provider will be assigned only one NPI, which is retained for a lifetime even if moves to another state.

question

optical character recognition

answer

OCR, A device that can read typed characters at very high speed and convert them to digitized files that can be saved on disk. also known as intelligent character recognition (ICR).

question

\"other\" claims

answer

Medicare claims not considered \"clean\" claims which require investigation or development on a prepayment basis (developed for Medicare Secondary Payer information).

question

paper claim

answer

A claim that is submitted on paper including optically scanned claims that are converted to electronic form by insurance companies. Paper claims may be typed or generated via computer.

question

pending claim

answer

An insurance claim that is held in suspense for review or other resons by the 3rd-party payer. These may be cleared for payment or denied.

question

Pending or Suspense Claim category

answer

Other claims placed in \"dirty claim\" category because something is holding the claim back from payment, perhaps review or some other problem.

question

physically clean claim

answer

A claim that has no staples or highlighted areas and on which the bar code area has not been deformed.

question

rejected claim

answer

A claim that has not be processed or cannot be processed for various reasons (e.g., the patient is not Identified in the payer system, the records, or the claim was not submitted in a timely manner.)

question

Rejected claim process

answer

A rejected claim is one that requires investigation and needs further clarification and possibly answers to some questions. Such a claim should be resubmitted after proper corrections are made.

question

Social Security Number

answer

If provider DOES NOT have an EIN, then SSN may be required.

question

state license number

answer

To practice within a state, a physician must obtain state license number. Sometimes this number is requested on forms and is used as a provider number.

question

Taxonomy code

answer

administrative code set under HIPAA that is used to report a physician's specialty when it affects payment (see pg. 222)

question

CMS-1500

answer

Centers for Medicare and Medicaid Services claim form. Form developed so that insurance carriers could process claims efficiently by OCR.

question

DME

answer

Durable medical equipment

question

DNA

answer

does not apply

question

EIN

answer

employer identification number

question

EMG

answer

emergency

question

EPSDT

answer

early periodic screening, diagnosis, and treatment

question

FDA

answer

Food and Drug Administration. The agency that is responsible for determining if a food or drug is safe and effective enough to be sold to the public.

question

HHA

answer

Home Health Agency

question

ICR

answer

intelligent character recognition

question

IDE

answer

investigation device exemption

question

LMP

answer

last menstrual period

question

MG

answer

Medigap

question

MSP

answer

Medicare Secondary Payer

question

NA, N/A

answer

not applicable

question

NOC

answer

not otherwise classified

question

NPI

answer

National provider Identification

question

OCNA key

answer

other carrier name and address key

question

OCR

answer

optical character recognition (OCR), also less commonly referred to as intelligent character recognition (ICR).

question

PAYERID

answer

payer identification

question

PRO

answer

peer review organization or professional review organization

question

SOF

answer

signature on file

question

SSN

answer

social security number

question

TMA

answer

Tricare Management Activity

question

Abstracting from Medical Records

answer

3 situations: 1. to complete insurance claim form 2. when sending a letter to justify a health insurance claim after professional services are rendered 3. when patient applies for life, mortgage, or health insurance

question

dual coverage

answer

two insurance polices are involved, also called duplication of coverage, one is considered primary and the other secondary.

question

provider numbers

answer

claims may require several NPI numbers, one for referring physician, one for the ordering physician, and one for the performing physician (billing entity).

question

Non clean claims

answer

other types of claims are called dirty when a claim is submitted with errors, incomplete when missing required information, invalid when illogical or incorrect, pending when a claim is held in suspense for review, rejected when the claim needs investigation and answers to some questions, or deleted when the Medicare fiscal intermediary cancels, deletes, or voids a claim.

question

A diagnosis should never be submitted on an insurance claim without supporting documentation in the medical record.

answer

true

question

Every insurance claim should be proofread for completeness and accuracy of content before it is submitted to the insurance carrier.

answer

true

question

Be aware of common billing errors and learn how to correct them for quicker claim settlements and to reduce the number of appeals.

answer

true

question

HIPAA transactions and code sets standards only apply to electronic transactions conducted by covered entitites.

answer

true

question

Copies of submitted insurance claim forms should be filed in a tickler file and reviewed for follow-up every 30 days unless the computer system maintains the files.

answer

true

question

Be sure the correct NPI is shown on the claim by the physician rendering the medical service to the patient

answer

true

question

When two insurance policies are involved (dual coverage or duplication of coverage), one is considered primary and the other secondary. First an insurance claim is submitted to the primary plan, and after payment the secondary carrier is billed with a copy of the explanation of benefits from the primary carrier.

answer

true

question

There are two types of claims submitted to insurance companies for payment: paper claims and electronic claims.

answer

true

Insurance Handbook, Chapter 7

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