Insurance Handbook Ch. 2

50 terms by gandecoe 

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CCI

Correct Coding Initiative - to detect improperly coded claims via computer edits

CMS

Centers for Medicare and Medicaid Services

CPT

Current Procedural Terminology

DHHS

U.S. Department of Health and Human Services

EDI

electronic data interchange (requires standardized formatting)

eHIM

electronic health information management - TXs in which health care info is accessed, processed, stored and transferred electronically

ePHI

electronic protected health information

HCPCS

Healthcare Common Procedure Coding System

HIPAA

Health Information Portability and Accountability Act of 1996, primarily Titles I and II

ICD-9-CM

International Classification of Diseases, Ninth Revision, Clinical Modificaiton

IIHI

individually identifiable health information - includes address, DOB, physical or mental health, provision of care, or payment for care - IIHI data identify the individual or establish reasonable basis to believe it can be used to ID the person

NPI

National Provider Identification Number, 10 digits assigned for a lifetime

NPP

Notice of Privacy Practices

OIG

Office of the Inspector General - safeguards health & wealthfare of Medicare/Medicaid beneficiaries & protect program integrity

OSHA

Occupational Safety and Health Administration

P&P

policies and procedures (of a provider or insurer), as determined by a privacy officer to comply with HIPAA

PHI

protected health information - IIHI in any form: paper, computerized, spoken words, x-ray-films - any info that identifies an individual and describes his/her health status, age, sex, ethnicity, or other demographic characteristics, whereh or not stored or transmitted electronically

PO

privacy officer ore privacy official - employed or contracted by provider to develop/set P & P and train/manage staff to be compliant with HIPAA

SNOMED

Systematized Nomenclature of (Human and Veterinary) Medicine

TCS

HIPAA transaction and code set

TPO

treatment, payment, and (routine) operations

compliance

meeting regulations, recommendations, and expectations of federal and state regulating agencies

"principles and practices" elements

regulations and recommendations to protect individuals, streamlining of processes, supporting system-wide stability

compliance strategy

like a user's manual - standardized process to enable consistent and effective compliance management

HIPAA Title I primary purpose

portability - continuous coverage when insureds change or lose jobs

HIPAA Title II primary purpose

development & implementation of standardized electronic TXs AND implementation of procedures to ensure privacy and security of individuals' health data

covered entities under HIPAA

transmit info via electronic TXs covered by HIPAA: third-party payers/insurers, providers, and clearinghouses

clearinghouses

scrub and redistribute provider claims to insurers

patient rights

receive NPP, access and request amendments to health records, receive an accounting of those who have received their health info, request restrictions on who can access their health records

OCR

Office of Civil Rights, which enforces privacy standards for Medicare and Medicaid

electronic media

internet, extranet, intranet, phone lines for transmission of data (including FTP and faxes), mag tape, disks, CDs

business associate

performs or assists in the performance of a function involving the use of individually identifiable health information, including claims processing or administration.... example: outside billing company

state preemption

when state law takes precedence over federal law - determined by the P.O.

privacy

condition of being secluded from the presence or view of others

confidentiality

use of discretion in keeping other's information private

consent form

NOT required before provider use/disclose PHI for TPO

consent

verbal or written agreement giving approval to some action, situation or statement

authorization

formal, written permission to use/disclose his/her identifiable health info for purposes other than TPO.

breach of confidential communication

unauthorized release of information, a HIPAA violation - breacher is required to mitigate harmful effects of the breach

HIPAA confidentiality exceptions

MCO management audit; highly contagious/infectious communicable disease; malfunction of medical device; patient is suspect in criminal investigation; assist in locating missing person, witness or suspect; subpeona, search warrant; lawsuit; suspicious death; 3rd party bill payer request; "common good"/public health state law as for abuse

medical code sets

data elements used uniformly to document diagnoses (ICD-9-CM) and procedures (CPT, HCPCS)

CPT

Current Procedural Terminology - produced by AMA; updated each January 1, Category III (emerging technology) codes also update in July

ICD-9-CM

International Classification of Diseases, 9th revision, clinical model - produced by U.S. DHHS; updated each October 1

HCPCS

HealthCare Common Procedure Coding Sytem - produced by CMS - updated each January 1 w/periodic updates as needed

Security Rule

regulations related to security of ePHI and electronic TXs - 1) admin safeguards/P&P; 2) tech safeguards/protect and control access to electronic info; 3) physical safeguards/prevent unauthorized physical access to computers, buildings

CMP law

Civil Monetary Penalties law - penalizes a person/org for making false, upcoded or medically unnecessary claims against any federal health care program; fines for noncompliance with privacy/security regulations; hefty fines and years of imprisonment for knowingly obtaining/disclosing IIHI, using it for personal gain

QUI TAM

private citizen brings a civil action on behalf of federal govt for a violation of the False Claims Act

STARK I and II

prohibit a provider from referring patients to an entity with which he/she has a financial relationship

COMPLIANCE PROGRAM GUIDANCE

published by OIG; guidance provided is recommended, but voluntary

COMPLIANCE PLAN

a provider's plan for reviewing billing processes (via audits) and establishing controls to correct weaknesses and prevent errors.

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