CH 8 CLAIM PREPARATION AND TRANSMISSION
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National Uniform Claim Committee (NUCC)
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organization responsible for claim content
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CMS-1500
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paper claim for physician services
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CMS-1500 (08/05)
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current paper claim approved by the NUCC
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legacy number
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provider's identification number issued prior to the NPI system
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carrier block
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data entry area in the upper right of the CMS 1500
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condition code
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two-digit numeric or alphanumeric codes used to report a special condition or unique circumstances
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pay-to-provider
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person or organization that will be paid for services on a HIPAA claim
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rendering provider
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an alternative physician who actually provides the procedure on a claim
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billing provider
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person or organization sending a HIPAA claim
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referring provider
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type of provider that transfers patient care to another provider
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qualifier
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two-digit code for a type of provider identification number other than the NPI
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place of service (POS) code
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administrative code indicating where medical services were provided
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administrative code set
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required codes for various data elements
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taxonomy code
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administrative code set used to report a physician's specialty
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data element
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smallest unit of information in a HIPAA transaction (i.e. patient first name, middle name or initial, and last name)
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required data element
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information that must be supplied on an electronic claim
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situational data element
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conditional on specific situations (i.e. the insured differs from the pt, the insured's name must be entered)
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responsible party
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other person or entity who will pay a patient's charges
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individual relationship code
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administrative code required if the patient and the insured are not the same person
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claim attachment
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documentation a provider sends a payer to support a claim
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clean claim
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claim accepted by a health plan for adjudication
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claim scrubber
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software that checks claims to permit error correction
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direct data entry
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method of transmitting a claim using internet based service where employees key in standard data elements
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diagnosis pointer
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used on a claim to indicate which procedure code and which diagnosis code are connected for the date of service
