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assignment of benefits

the transfer of the patient's legal right to collect benefits for medical expenses to the provider of those services, authorizing the payment to be sent directly to the provider


the process of examining claims for accuracy and completeness before submitting the claims; can be performed manually or electronically with computer billing software

audit trail

the path left by a transaction when it has been completed; often referred to when tracking medical services used by patients or researching claims

clean claim

an insurance claim form that has been completed correctly (no errors or omissions)


a centralized facility to which insurance claims are transmitted; separates, checks, and redistributes claims electronically to various insurance carriers

direct billing

a method of electronic claims submission in which computer software allows a provider to submit an insurance claim directly to an insurance carrier for payment

dirty claim

a claim form that contain errors or omissions; must be corrected and resubmitted to an insurance carrier to obtain reimbursement

electronic claim

a claim submitted to an insurance processing facility through a computerized medium, such as direct data entry, direct wire, dial-in telephone digital fax, or personal computer download or upload

electronic data interchange (EDI)

the transfer of data back and forth between two or more entities using an electronic medium

electronic (digital) signature

a scanned signature or other such mark that is accepted as proof of approval of and/or responsibility for the content of an electronic document

employer identification number (EIN)

the number used by the IRS to identify a business or individual functioning as a business entity for income tax reporting

rejected claim

claim returned unpaid to the provider for clarification of any question; must be corrected before resubmission

intelligent character recognition (ICR)

the electronic scanning of printed blocks as images and the use of special software to recognize these images (or characters) as ASCII text for upload into a computer database

National Provider Identifier (NPI)

a lifetime number consisting of 10 digits that Medicare uses to replace the Provider Identification Number (PIN) and the Unique Physician Identification Number (UPIN)


Provider Identification Number

Unique Provider Identification Number (UPIN)

a number assigned by fiscal intermediaries to identify providers on claims for services

paper claim

a hard copy of an insurance claim, which is completed and sent by surface mail


any company, individual, or group that provides medical, diagnostic, or treatment services to a patient


the universal claim form developed by the HCFA, now know as the CMS and approved by the AMA for use submitting all government-sponsored claims


Health Care Financing Administration


Centers for Medicare and Medicaid Services


American Medical Association

ASC X12N 837P (HIPPA Health Care Claims Professional)

the transaction and code set for the CMS-1500 electronic claims submission


a CMS-1500 claim form contains how many blocks


the blocks on a CMS-1500 form are divided into how many sections

Section 1

carrier block: address of insurance carrier (top of form)

Section 2

patient/insured: info about the patient and the insured (boxes 1-13)

Section 3

physician/supplier: info about the physician or supplier (boxes 14-33)


maximum number of codes that should be used on one claim form

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