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Exchange of data in a standardized format through computer systems is a technology known as

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Electronic data into a code interchange (EDI)

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The act of converting computerized data into a code so that unauthorized users are unable to read it is a security system known

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encryption

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Payment to the provider of service of an electronically submitted insurance claim may be received in approximately

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2 weeks or less

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List benefits of using HIPAA standards transactions and code sets.

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a. More reliable and timely processing - quicker reimbursement from player b. improved accuracy of data c.easier and more efficient access to information c. better tracking of transactions d. reduction in office expenses

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Dr. Morgan has 10 or more full-time employees and submits insurance claims for his Medicare patients. Is his medical practice subject to the HIPAA transaction rules ?

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YES

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Dr. Maria Montez does not submit insurance claims electronically and has five full- time employees. IS she required to aid by HIPPA transaction rule?

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NO

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Name the standard code sets used for the following :

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a.physician service: CPT-4 b. disease and injuries : ICD-9-CM c. pharmaceuticals and biologics : NDC national Drug Codes

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Name the levels for data collected to construct and submit an electronic claim

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a. High - level information b. Claim-level information c. Specialty claim-level information d. Service line-level information e. Specialty service line-level information f. Other information

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The most important function of a practice management system is

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Accounts receivable

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To look for correct all errors before the health claim is transmitted to the insurance carrier, you may

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print an insurance billing worksheet or perform a front-end edit (online error checking)

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Add on software to a practice management system that can reduced the time it takes to build or review a claim before batching is known as a / an

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encoder

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Software that is used in a network that serves a group of users working on a related project allowing access to the same data is a /an

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grouper

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An alert feature that may be incorporated into the software in a physician's office that finds errors so they may be corrected before transmitting an insurance claim is called a/ an

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Online error-edit process

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Under HIPAA, data element that are used uniformly to document why patients are seen (diagnosis) and what is done to them during their encounter (procedure) are known as

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Medical code sets

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The standard transaction that replaces the paper CMS-1500 ()*-05) claim form and more than 400 versions of the electronic National Standards Format is called the

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837P

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A paperless computerized system that enables payments automatically to be transferred to a physician's bank account by third -party may be done via

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electronic funds transfer (EFT)

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An electronic Medicare remittance advice that takes the place of a paper Medicare explanation on benefits (EOB) is referred to as :

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ANSI 820

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batch

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a group of claims for different patients sent at the same time from one facility.

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audit trail

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a chronologic record of submitted data that can be traced to the source to determine the place of origin.

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Paper and electronic claims begin

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before, during, and after service is rendered..

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Online error edit process

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alerts the person processing the claim to any errors immediately so that the correction can be made before transmission of the claim.

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Clearinghouse

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receives the electronic transmission of claims from the health care provider and translates it into a standard format prescribed in HIPAA regulations.

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Clearinghouse duties

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separating the claims by carrier performing software edits on each claim to check for errors transmitting claims electronically to correct the insurance payer

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carrier direct

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medical practices link directly to the insurance carrier without the use of a clearinghouse

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electronic medical claims (EMC)

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used for nearly all Medicare transactions, including claims submission, payment, direct deposit, online eligibility verification, coordination of benefits, and claims status.

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MTS

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Medicare Transaction System Part A (hospital services) Part B (Outpatient medical services)

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Advantages of a Clearinghouse

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Translation of formats to HIPAA compliant format Reduction in time of claims processing Cost effective through loss prevention Fewer claims rejections Fewer delays in processing More accurate coding with claims edits Consistent reimbursement

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HIPAA Transaction and Code Set Rule (TCS)

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achieve a higher quality of care reduce administrative costs by streamlining the processing of routine administrative and financial transactions

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Benefits of TCS and EDI

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More reliable and timely processing Improved accuracy of data Easier and more efficient access to information Reduction of data entry Reduction in office expenses

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Standard Transactions

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electronic files in which medical data are compiled to produce a specific format to be used throughout the health care industry

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Code sets

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Allowable sets of codes that anyone could use to enter into a specific space on a form.

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Data elements

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Medical codes sets used uniformly to document why patients are seen.

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supporting codes sets

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encompass both medical and nonmedical data

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Standard Code Sets include

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ICD-9-CM CPT-4 CDT (Code on Dental Procedures and Nomenclature) NDC ICD-10-CM

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Other data elements required under HIPAA TCS

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Taxonomy codes Patient Account number Relationship to patient Facility code value Patient signature source code

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Taxonomy

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Science of Classification; include general practice, family practice, nurse practitioner. These are necessary because some institutional providers may not choose to apply for an NPI

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Accredited Standards Committee X12 (ASC X12)

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American National Standards Institute formed this which developed the US standards body for the cross industry development, maintenance, and publication of ED exchange standards

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Standard Unique Identifiers

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EIN NPI HPI UPI

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Accounts recievable

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The most important function of a practice management system

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Practice Management System (PMS)

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goal is the ability to prepare, send, receive, and process HIPAA standard electronic transactions.

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Encounter form

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document used to record information about the service rendered to a patient.

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encoder

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add on software to PMS that can greatly reduce the time it takes to build or review a claim before batching.

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audit tool

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the encoder can be helpful in performance improvement by identifying problem areas in the billing process

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grouper

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software designed for use in a network that serves a group of users working on a related project that allows access to the same data.

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Methods to ensure clean claims

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Claim scrubber software Encoder software Electronic Clearinghouse Single and batch claim review

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Interactive transactions include

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Real time EFT

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Carrier direct system

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Fiscal agents for medicare, Medicaid, TRICARE, and private third party payers use this system

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Administration Simplification Enforcement Tool ASET

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enables individuals or organizations to file a complaint online against an entity "whose actions impact the ability of a transaction to be accepted and or efficiently processed".

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Daily Guidelines and Protocols

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Post charges in practice Management system Post payments in PMS Batch, scrub, edit, and transmit claims; retrieve transmission reports Review Clearinghouse/payer transmission reports Audit claims batched and transmitted with confirmation reports Correct rejections and resubmit claims

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Weekly Guidelines and Protocols

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Batch, scrub, edit, and transmit claims Analyze previous weeks rejected and resubmitted claims Note any problematic claims and resolve outstanding files Research unpaid claims Make follow up calls to resolve reasons for rejections, such as incorrect NPI, incorrect data, incomplete data or wrong format

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End of Month Guidelines and Protocols

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Run month end aging reports Review all claim rejection reports, making sure all problems are resolved and claims resubmitted Update PMS with payer info, such as EIN and NPI Run patient statements in office or through clearinghouse

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Reasonable Safeguards

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measurable solutions based on accepted standards that are implemented and periodically monitored to demonstrate that the office is in compliance.

Ch. 8; Electronic Data Interchange: Transactions and Security

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