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electonic data interchange (EDI)
A process that sends information back and forth between two or more individuals by computer linkages.
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 ______.
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
For electronic claims submission, the phrase _____ is printed in place of the patient or provider signatures.
signature of file
The _____ function of electronic claims processing software identifies invalid procedure codes.
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
Electronic records management systems include the same components as a record management system for paper files.
All records---either electronic or paper---must be stored in a(n) _____ area.
Computer monitor _____ are one of the tools available to protect confidential information.
_____assigned to previous employees should be deleted from all electronic or computer program files.
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.
Interactive communication is a time-consuming way to identify and correct insurance claims data.
The _____ electronic claims submission method allows the provider to communicate directly with the insurance company.
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
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