question

1) **Fill-in Question** Define encryption

answer

is used for security purposes to assign a code to represent data. It is a \"secret code\" that makes data unintelligible to unauthorized parties.

question

2) Why are electronic transmissions encrypted?

answer

so that they cannot be opned and read if intercepted (received) by the wrong individual.

question

3) Define batch

answer

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

question

4) When can payments be received after electronic transmissions?

answer

in 2 weeks or less

question

5) What is an important advantage of the electronic claims submission?

answer

the on-line error-edit process that may be incorporated into the software in the physician's office, clearinghouse, or insurance company.

question

6) Define clearinghouse

answer

is an entity that receives the electronic transmission of claims (EDI) from the health care provider's office and translates into a standard format in HIPAA regulations.

question

7) What are the clearinghouse's duties?

answer

to separate the claim by carrier, perform software edits on each claim to check for errors, and to transmit claims electronically to the correct insurance payer.

question

8) Under HIPAA, what circumstances would likely make a provider a covered entity and therefore they must comply with HIPAA compliance?

answer

1) if the provider submits electronic transactions 2) Large providers: if the provider submits paper claims to Medicare and has 10 or more employees.

question

9) What is a benefit of TCS (HIPAA Transaction and Code Set) and EDI (Electronic Data Interchange)?

answer

fast eligibility evaluation (reduce time of claim life cycle) and improves cash flow. Average turnaround for electronic claims are 9-15 days versus 30-45 days for paper claims.

question

10) Under HIPAA, what circumstances would likely NOT make a provider a covered entity?

answer

1) If the provider has fewer than 10 employees and submits only paper claims to Medicare. 2) if the provider only submits paper claims until and after April 14, 2003 and does not send claims to Medicare

question

11) Define Code Sets

answer

they are allowable sets of codes that anyone could use to enter information into a specific space (field) on a form.

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12) Medical codes are what?

answer

data elements

question

13) How are data elements used?

answer

uniformly to document why patients are seen (diagnosis, ICD-9-CM) and what is done to them (procedure, CPT-4 & HCPCS) during their encounter.

question

14) What is an EIN?

answer

employer identification number assigned by the IRS (Internal Revenue Service)

question

15) What is an EIN used for?

answer

to identify employers for tax purposes.

question

16) In 837P Data elements: Insured Name (Last, First, Middle) are what?

answer

situational

question

17) What is the most important function of a Practice Management System?

answer

Accounts Receivable

question

18) What is a PMS?

answer

Practice Management System

question

19) What are other names for an encounter form?

answer

1) charge slip 2) multipurpose billing form 3) Patient service slip 4) routing form 5) super bill 6) transaction slip

question

20) What is an encounter form?

answer

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

question

21) **Fill-in Question** What is a prompt?

answer

a question asked (on the screen) in which you key in a response

question

22) What is the first \"DO\" when keying in data and billing electronic claims?

answer

use the patient's account number to differentiate between patients with similiar names

question

23) What is the second \"DO\" when keying in data and billing electronic claims?

answer

use correct numeric service location codes, current valip CPT codes, or Healthcare Common Procedure Coding System (HCPCS) procedure codes.

question

24) What is the third \"DO\" when keying in data and billing electronic claims?

answer

print an insurance billing worksheet or perform a front-end edit (on-line error checking) to look for errors and correct them before submitting the claim to the third-party payer.

question

25) What is the fourth \"DO\" when keying in data and billing electronic claims?

answer

request electronic-error reports from the third-party payer to make corrections to the system.

question

26) What is the last \"DO\" when keying in data and billing electronic claims?

answer

obtain and cross-check the electronic status report against all claims transmitted.

question

27) What is the first \"DON'T\" when keying in data and billing electronic claims?

answer

use special characters (dashes, spaces, or commas)

question

28) What is the last \"DON'T\" when keying in data and billing electronic claims?

answer

bill codes using modifiers -21 or -22 electronically (unless the carrier receives attachments) to justify more payment.

question

29) During the edit and error process, software code indentify what?

answer

invalid codes, age conflicts, gender conflicts, procedural and diagnostic code conflicts, and other data before issuing payments.

question

30) What is an encoder?

answer

is an add-on software to practice management systems that can greatly reduce the time it takes to build or review a claim before batching.

question

31) When using an encoder: the billing specialist or other user is prompted with what?

answer

with a series of questions or choices leading to pr affecting a specific code assignment by displaying code-specific edits.

question

32) For assignment of benefits, what must be obtained?

answer

each patient's signature. The signature must be obtained and retained in the office records because there are no handwritten signatures on electronic claims.

question

33) What is Interactive Transaction?

answer

is back-and-forth communication between two computer systems.

question

34) **Fill-in Question** What is an ERA?

answer

Electronic remittance advice - an online transaction about the status of a claim.

question

35) What information does the ERA give?

answer

information on charges paid or denied.

question

36) Date entry is not required in an ERA if?

answer

the medical practice elects to get the software system to automatically post the information to patients' accounts

question

37) What system do fiscal agents such as Medicaid, Medicare, TRICARE, and many private third-party payers use?

answer

the carrier-direct system

question

38) How does the carrier-direct system work?

answer

the data is transmitted electronically, directly into the payer's system which eliminated the need for a clearinghouse.

question

39) How do clearinghouses charge?

answer

may charge a flat rate per claim or a monthly charge.

question

40) Regardless of submission through carrier-direct or a clearinghouse reports are generated and accessible to do what?

answer

track each function of the claims process.

question

41) Define scrubber report

answer

indicates the total number of claims, charges, and dollar amounts that were received by the clearinghouse and scrubbed to Massachusetts Insurance Plan.

question

42) When claims have been submitted through the clearinghouse, the billing specialist does what?

answer

review the scrubber report for each insurance payer

question

43) What do security measures encompass?

answer

all the administrative, physical, and technical safeguards in an information system.

question

44) What does the Security rule address?

answer

only electronic protected health information (ePHI) but the concept of protecting PHI (which becomes ePHI) puts emphasis on security for the entire office.

question

45) The security rule is divided into what three sections?

answer

1) Administrative safeguards 2) Technical safeguards 3) Physical safeguards

question

46) **Fill-in Question** What do administrative safeguards do?

answer

they prevent unauthorized use or disclosure of PHI through administrative actions that manage the selection, development, implementation, and maintenance of security measures to protect ePHI.

question

47) Administrative safeguards - management controls do what?

answer

guard data integrity, confidentiality, and availability.

question

48) Administrative safeguards include what?

answer

internal audits which allow the ability to review who has had access to ePHI to ensure there is no intentional or accidental inappropriate access (in PMS and paper records or charges).

question

49) **Fill-in Question** What are technical safeguards?

answer

technological controls in place to protect and control access to information on computers in health care organization.

question

50) Technical safeguards include what?

answer

automatic payoffs to prevent unauthorized users from accessing a computer when it is left unattended.

question

51) **Fill-in Question** What do physical safeguards do?

answer

prevent unauthorized access to PHI. These physical measures and P&P protect a covered entity's electronic information systems and related building and equipment from natural and unauthorized intrusion.

question

52) Physical safeguards policies include what?

answer

how the office handles the retention, removal, and disposal of paper records, as well as recycling of computers and destruction of obsolete data disks or software programs containing PHI.

question

53) **Fill-in Question** Define Backup

answer

means to save data frequently (preferably daily). a duplicate data file which may be used to complete or redo the operation if the primary equipment fails.

question

54) **Fill-in Question** Define password

answer

a combination of letters and numbers that each individual is assigned to access computer data. Passwords should be changed at regular intervals and never written down.

question

55) **Fill-in Question**

answer

The person who is responsible and accountable

question

56) **Matching** Daily Guidelines and Protocols

answer

1) Post charges in PMS (2) Post Payments in PMS 3) Batch, scrub, edit, and transmit claims; retrieve transmission reports (4) Run day sheet (5) Review clearinghouse/payer transmission confirmation reports 6) Audit claims batched and transmitted with confirmation reports. (7) Correct rejections and resubmit claims

question

57) **Matching** Weekly Guidelines and Protocols

answer

1) Batch, scrub, edit, and transmit claims; retrieve transmission reports (2) Analyze previous weeks rejected and resubmitted claims (3) Note any problematic claims and resolve outstanding files (4) Research unpaid claims. 5) Make follow-up calls to resolve reasons for rejections (such as incorrect NPI, missing patient ID, incomplete data elements and wrong format).

question

58) **Matching** Monthly Guidelines and Protocols

answer

1) run month-end aging report 2) Review all claim rejection reports (clearinghouse and payer), making sure all problems are resolved and claims accepted (3) update PMS with payer information (such as EIN and NPI). (4) Run patient statements in office or through clearinghouse

question

59) Where should backup files be stored?

answer

copies should be placed away from the office in case of fire, flood, or theft.

question

60) BMT?

answer

Bone Marrow Transplantation

question

61) BSE?

answer

Breast Self-Examination

question

62) cc?

answer

cubic centimeters

question

63) AP?

answer

anteroposterior

question

64) AUB?

answer

Abnormal Uterine Bleeding

question

65) C?

answer

Carbon or Calorie

question

66) c/o?

answer

Complaint of

question

67) @?

answer

at

question

68) BSO?

answer

Bilateral Salphingoorphorectomy

Flashcards on Insurance Handbook – Chapter 8

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