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29 terms

21 The Health Insurance Claim Form

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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
audit
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)
clearinghouse
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)
PIN
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
provider
any company, individual, or group that provides medical, diagnostic, or treatment services to a patient
CMS-1500
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
HCFA
Health Care Financing Administration
CMS
Centers for Medicare and Medicaid Services
AMA
American Medical Association
ASC X12N 837P (HIPPA Health Care Claims Professional)
the transaction and code set for the CMS-1500 electronic claims submission
33
a CMS-1500 claim form contains how many blocks
3
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)
4
maximum number of codes that should be used on one claim form