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50 terms

Insurance Handbook Ch. 2

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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.