question

CMS 100 -

answer

paper claim submitted to TPP for reinbursement ( paper claim )

question

HIPPA x12 837 -

answer

electronic form used to send a claim ( HIPPA 837 P claim (electronic)

question

HIPPA requires electronic transmission of claims by all providers with _________ employees.

answer

10 or more

question

National Uniform Claim Commitee (NUCC) -

answer

organization responsible for claim content

question

CMS - 1500 (02/12) -revised-

answer

current paper claim approved by the NUCC

question

5010 version -

answer

new format for the EDI transactions (data exchange electronic)

question

The CMS - 1500 claim has a _________________________________ and _____ item numbers (INs)

answer

carrier block and 33 item numbers

question

Carrier Block -

answer

data entry area in the upper right of the CMS - 1500

question

Condition code -

answer

two digit numeric or alphanumeric codes used to report a special condition or unique circumstance.

question

The upper portion of the CMS - 1500 claim form ( ITEM Numbers 1-13) :

answer

lists demographic information about the patient and specific information about the patients insurance coverage.

question

Insurance is entered based on

answer

the patient information form, insurance card, and payer verification .

question

Types of providers (4)

answer

1. pay to provide 2. rendering provider 3. Billing provider 4. referring provider

question

Pay to provider -

answer

person or organization that will be paid for services on a HIPPA claim

question

Rendering provider -

answer

term used to identify an alternative physician or professional who provides the procedure .

question

Billing provider -

answer

person or organization sending a hippa claim

question

Physician / Supplier information section ( CMS 1500 ) -

answer

this section identifies the healthcare provider, describes the services performed and gives the payer additional info to process the claim

question

Other ID number ( CMS 1500 ) -

answer

additional provider identification number

question

Qualifier ( CMS 1500 ) -

answer

two digit code for a type of provider identification number other that the NPI

question

Outside laboratory (CMS 1500 ) -

answer

purchased laboratory services .

question

Service line information ( CMS 1500)

answer

information about services being reported

question

Place of Service ( POS ) code (CMS 1500 ) -

answer

(24. B ) administrative code indicating where medical services were provided

question

Taxonomy Code (CMS 1500) -

answer

administrative code set used to report a physicians specialty

question

administrative code set (CMS 1500 ) -

answer

required codes for various data elements.

question

The lower portion of the CMS 1500 claim form ( item numbers 14-33 ) :

answer

contains information about the provider or supplies and the patients condition, including the diagnosis, procedures, and charges (information is based on the encounter form )

question

Data element ( 837 claim )

answer

smallest unit of information in a HIPPA transaction . Example : A patients name

question

Required data element ( 837 claim )

answer

information that must be supplied on an electronic claim

question

Situational data element -

answer

information that mst be on a claim in conjunction with certain other data elements.

question

5 sections of the HIPPA 837 claim :

answer

Provider information subscriber information payer information claim information service line information

question

Responsible party ( 837P claim )

answer

other person or entity who will pay a patients charges

question

claim filing indicator code (837P ) -

answer

administrative code that identifies the type of health plan

question

individual relationship code (837P) -

answer

administrative code specifying the patients relationship to the subscriber

question

destination payer (837P )

answer

health plan receiving a HIPPA claim

question

Claim control number (837P)

answer

unique number assigned to a claim by the sender

question

Claim frequency code or claim submission reason code (837p)

answer

adminisytrative code that identifies the claim as original , replacement, or void/ cancel action

question

line item control number

answer

unique number assigned to each service line item reported q

question

claim attachment -

answer

additional data in printed or electronic format sent to support a claim . Examples : include lab results , specialty consultation notes, and discharge notes.

question

Clean claim -

answer

claim accepted by a health plan for adjudication. properly completed and contains all the necessary information .

question

HIPPA x12 276/277 Health care claim status Inquiry / Response

answer

electronic format used to ask payers about claims .

question

277 -

answer

response

question

276 -

answer

inquiry

question

Claim scrubber -

answer

soft ware that checks claims to permit error correction

question

Transmission of electronic claims through three major methods ;

answer

1. in the direct transmission approach , providers and payers exchange transactions directly 2. The majority of providers use clearinghouses to send and receive data incorrect EDI format 3. Some payers offer online direct data entry (DDE) to providers, which involves using an Internet- based service into which employees key the standard data elements

Medical Billing and Coding Chapter 7

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