EMC, ERA and Adjustment Entries Explained
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What is the name of the paper document explaining the insurance payment to the provider?
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Remittance advice or EOB
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What is the name of the accounting entry posted to reduce the original charge to the allowed amount?
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Write down adjustment
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What does EMC stand for?
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Electronic media claims
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What does ERA stand for?
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Electronic remittance advice
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What does EDI stand for?
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Electronic data interchange
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What is the name of the period of time hospitals delay building?
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Bill-hold
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What is meant by the term payment-floor?
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Delay that Medicare intermediaries use before they have to pay the claim
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Name four of the EDI transactions required by HIPAA?
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Claim status inquiry and response, eligibility benefit inquiry and response, referral certification and authorization, health plan premium payments
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Name two types of patient statements
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Balance forward (begins with previous month's balance and shows only charges in current period) and open item (shows all unpaid items with payment adjustments)
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What are claim edits?
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Examine received claims prior to adjudicating them
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What is the difference between real time and batch posting?
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Real time is commonly used in medical offices and allows collection of copay from patient and shortens billing cycle. Batched is mainly used by hospital billing and the bills are not entered on the same day of the visit
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Which paper form was designed for professional claims?
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CMS-1500
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T/F: HIPAA requires all but the smallest health plans to receive claims electronically
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True
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T/F: A separate EMC file must be created for each claim
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False
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T/F: The first step in preparing a claim is to calculate the DRG
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False
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What does ANSI stand for?
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American National Standard Institute
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What is posting?
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Entering procedure and diagnosis data for billing into the patient account system
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What happens if a payer has secondary insurance?
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Must wait until payment is received from the primary insurance before billing the secondary plan
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What is COB?
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Coordination of benefit - when insurance is sent to two different insurance groups
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What organizations under HIPAA can organize batches of claims and forward them?
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Clearinghouses
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What are claim scrubbers?
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Special software that examines claim data before it is sent to eliminate preventable billing errors
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What is the amount a payment owes called?
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Accounts receivable
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What is the first step in the billing workflow?
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Providers verify patient insurance eligibility
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What is CDA?
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Clinical document architecture
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What does SNF stand for?
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Skilled nursing facility
