Ch 7 The Paper Claim

Flashcard maker : Linda Lynch
Who developed the Standard Form?
HIAA & AMA
State the name of the insurance form approved by the American Medical Association.
Universal Claim form – CMS-1500 (08-05)
Does Medicare accept the CMS-1500 (08-05) claim form?
Yes. It is required.
What is dual coverage?
When two insurance policies are involved. A primary and a secondary.
The insurance company with the first responsibility for payment of a bill for medical services is known as the.
Primary payer.
What important document must you have before an insurance company can photocopy a patient’s chart?
Release of Information Form signed by the patient.
If the patient brings in a private insurance form that is not group insurance, where do you send the form after completion?
To the Insurance Company
An insurance claim is returned for the reason \”diagnosis incomplete.\” State one or more solutions to this problem on how you would try to obtain reimbursement.
Resubmit.
When preparing a claim that is to be optically scanned, birth dates are keyed in with how many digits?
Eight. MMDDYYYY
Define this abbreviation: MG/MCD
Medigap-Medicaid
A three-part information form that is completed and signed by an insurance agent and an individual to obtain insurance coverage, and requires a medical examination by a physician is known as:
life or health insurance application
The insurance claim form required when submitting Medicare claims is:
CMS-1500 (08-05) claim form
The maximum number of diagnostic codes in the ANSI 837P claim format for transmitting for transmitting electronic health insurance claim is:
eight
If a patient’s gender is not indicated in the CMS-1500 (08-05) claim form, the gender block defaults to:
female
If a provider or medical services does not have a NPI number, the characters or digits that must be entered in Block 24I is/are:
IC
False
A photocopy of claim form may be optically scanned.
False
Handwriting is permitted on optically scanned paper claims.
True
A CMS-assigned National Provider Identifier (NPI) number consists of 10 characters.
False
When listing a diagnostic code on an insurance claim, insert the deceimal point.
True
A diagnosis reference pointer should be entered in Block 24E and not ICD-9-CM diagnostic code.
Clean Claim
an insurance form that is complete without errors.
Deleted Claim
the claim has not been processed or cannot be processed for various reasons.
Dirty Claim
a claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment
Durable Medical Equipment (DME) Number
A group or individual provider number used when submitting bills for specific medical supplies, devices, and equipment to the Medicare fiscal intermediary for reimbursement.
Electronic Claim
a health care claim that is transmitted electronically; also known as an electronic media claim (EMC)
Employer Identification Number (EIN)
The number used by the Internal Revenue Service that identifies a business or individual functioning as a business entity for income tax reporting.
Facility Provider Number
a facility’s provider number used to bill for services to show WHERE procedure was done
Group National Provider Identifier (Group NPI)
A number assigned to a group of physicians submitting insurannce cliams under the group name and reporting income under one name.
Health Insurance Claim Form (CMS-1500 [08-05])
CMS 1500; universal insurance claim
Incomplete Claim
is any Medicare claim missing required information
Intelligent Character Recognition (ICR)
A device that can read typed characters at very high speed and convert them to igitized files that can be saved on disk. (also known as OCR, Optical character recognition)
Invalid Claim
any medicare claim that contains complete, necessary information but is illogical or incorrect
National Provider Identifier (NPI)
A lifetime number consisting of 10 digits that Medicare will use to replace the Provider Identification Number(PIN) and the Unique Physician Identification number (UPIN).
Optical Character Recognition (OCR)
A device that can read typed characters at very high speed and convert them to igitized files that can be saved on disk. (also known as ICR, intelligent character recognition)
\”Other\” Claims
Medicare claims not considered \”clean claims\” wich require investigation or development on prepayment basis.
Paper Claims
submitted using CMS-1500 and mailing it to the insurance company to be optically scanned
Pending Claims
is a claim that has been held in suspense while it is being reviewed or waiting for additional information
Physically Clean Claim
Insurance claims with no staples or highlighted areas. The bar code areas has not been deformed.
Rejected Claim
an insurance claim submitted to an insurance carrier that is discarded by the system because of a technical error or because it does not follow medicare instructions
Social Security Number (SSN)
An individual’s tax identification number issued by the federal government.
State License Number
A number issued to a physician who has passed the state medical examinhation indicating his or her right to practice medicine in the state where issued.
AIDS
Acquired Immune Deficiency Syndrome
AMA
American Medical Association
CLIA
Clinical Laboratory Improvement Amendments
CMS-1500
Centers for Medicare and Medicaid Services Health Insurance Claim Form
COB
coordination of benefits
DME
durable medical equipment
DNA
does not apply
ECG
electrocardiogram
EIN
Employer Identification Number
EMG
emergency
EOB
Explanation of Benefit
EPSDT
early, periodic, screening, diagnosis, and treatment
FDA
Food and Drug Administration
HHA
home health agency or hospice health agency
HICN
?
HIPAA
Health Insurance Portability and Accountability Act
HIV
Human Immunodeficiency Virus
HMO
Health Maintenance Organization
ICR
intelligent character recognition
IDE
investigational device exemption
LMP
last mentrual period
MCD
Medicaid
MG
Medigap
MSP
Medicare Secondary Payer
NA, N/A
not applicable
NOC
not otherwise classified
NPI
National Provider Identification Number
NPP
non physician practitioner
OCNA key
other carrier name and address key
OCR
optical character recognition
PAYERID
payer identification
PRO
peer review organization or professional review organization
SOF
signature on file
SSN
Social Security Number
TMA
Tricare Management Activity
AIDS
Acquired Immune Deficiency Syndrome
AMA
American Medical Association
CLIA
Clinical Laboratory Improvement Amendments
CMS-1500
Centers for Medicare and Medicaid Services Health Insurance Claim Form
COB
coordination of benefits
DME
durable medical equipment
DNA
does not apply
ECG
electrocardiogram
EIN
Employer Identification Number
EMG
emergency
EOB
Explanation of Benefit
EPSDT
early, periodic, screening, diagnosis, and treatment
FDA
Food and Drug Administration
HHA
home health agency or hospice health agency
HICN
?
HIPAA
Health Insurance Portability and Accountability Act
HIV
Human Immunodeficiency Virus
HMO
Health Maintenance Organization
ICR
intelligent character recognition
IDE
investigational device exemption
LMP
last mentrual period
MCD
Medicaid
MG
Medigap
MSP
Medicare Secondary Payer
NA, N/A
not applicable
NOC
not otherwise classified
NPI
National Provider Identification Number
NPP
non physician practitioner
OCNA key
other carrier name and address key
OCR
optical character recognition
PAYERID
payer identification
PRO
peer review organization or professional review organization
SOF
signature on file
SSN
Social Security Number
TMA
Tricare Management Activity

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