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Health Insurance Billing - Chapter 10

Electronic Data Interchange (EDI)
STUDY
PLAY
CMS
Centers for Medicare and Medicaid Services
ECS
electronic claims submission
EDI
electronic data interchange
HIPAA
Health Insurance Portability and Accountability Act
PHI
protected health information
TPA
third-party administrator
electonic data interchange (EDI)
A process that sends information back and forth between two or more individuals by computer linkages.
electronic claim
A claim that is submitted to the insurance carrier by computer modem or computer download or upload via the Internet.
The identification of provider and insurance carrier responsibilities for accurate coding is part of ______.
compliance monitoring
The length of time from claims submission to claims payment is known as _____.
turnaround time
In order to establish electronic claims submission, the provider must _____.
execute a contract with insurance carriers or a clearinghouse
Confidentiality safeguards for electronic claims submission include _____.
assigning and periodically changing passwords
The process of sending information between two or more individuals via computer linkage is called _____.
electronic data interchange
Another name for clearinghouse is _____.
third-party administrator
For electronic claims submission, the phrase _____ is printed in place of the patient or provider signatures.
signature of file
As with paper claims submission, _____ is the most important factor in ECS.
accuracy
The _____ function of electronic claims processing software identifies invalid procedure codes.
error-edit
______ is defined as the ability to share information online.
interactive communication
Four advantages of electronic claims submission:
saves time and money associated with mailing the claims, no paper storage, creates an audit trail, errors corrected almost immediately, improved cash flow
False
Confidentiality laws for paper records do not apply to electronic records.
False
Staff members should share a common password for efficient access to insurance files.
True
Confidential information should never be stored on a computer's hard drive.
True
A written policy should address electronic claims submission and confidentiality.
True
Electronic records management systems include the same components as a record management system for paper files.
Electronic records are usually filed _____.
numerically
_____ must be backed up regularly.
electronic claims
All records---either electronic or paper---must be stored in a(n) _____ area.
secure; climate-controlled
Computer monitor _____ are one of the tools available to protect confidential information.
privacy panels
_____assigned to previous employees should be deleted from all electronic or computer program files.
passwords
False
The CMS-1500 is made obsolete when using electronic claims submission.
True
Electronic claims submission software programs edit insurance claims data for accuracy.
True
A pattern of coding errors can trigger an investigation of fraud or abuse.
True
The provider is responsible for assigning accurate diagnostic and procedure codes. Note: Even if medical coders actually do the coding, the ultimate responsibility rests with the provider, agency, or physician.
False
Interactive communication is a time-consuming way to identify and correct insurance claims data.
electronic claim
A(n) _____ is submitted to the insurance carrier via the Internet.
clearinghouse
A(n) _____ distributes claims to the appropriate insurance carrier.
carrier-direct
The _____ electronic claims submission method allows the provider to communicate directly with the insurance company.
error-edit
_____ is a process that checks the claim for accuracy and completeness.
unique identifier
The clearinghouse assigns a(n) _____ to each insurance company (carrier).
Components of an electronic claims processing agreement:
cost of software; staff training; turnaround time; updates; service
Components of an electronic claims processing agreement required by HIPAA:
how the information is submitted; who has access to the information; security features; storage and retention policies
Differences between carrier-direct and clearinghouse electronic claims submission options:
Carrier-direct: provider retains control of claims submission; medical records are available; immediate feedback to error-edit messages; separate agreement for each insurance carrier.
Clearinghouse: third-party involved in clams submissions; one agreement covers all submissions; equipment and software may be supplied by the clearinghouse
Three types of information required by nearly all insurance carriers:
patient demographic information, insurance program information, treatment or clinical information
Two edits often included in insurance billing software:
invalid diagnosis related to age, gender; invalid diagnosis and treatment codes; E/M code verification
Sources and source documents for retrieving information for electronic claims submission:
patient database, medical record, registration form, encounter form
HIPAA's impact on electronic claims submission:
HIPAA mandates security and privacy of electronic protected health information; controlled access; non-redisclosure policies/procedures; storage and retention policies; procedures. HIPAA also encourages electronic claims submission of Medicare claims.