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Electronic Data Interchange (EDI)


Centers for Medicare and Medicaid Services


electronic claims submission


electronic data interchange


Health Insurance Portability and Accountability Act


protected health information


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.


The _____ function of electronic claims processing software identifies invalid procedure codes.


______ 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


Confidentiality laws for paper records do not apply to electronic records.


Staff members should share a common password for efficient access to insurance files.


Confidential information should never be stored on a computer's hard drive.


A written policy should address electronic claims submission and confidentiality.


Electronic records management systems include the same components as a record management system for paper files.

Electronic records are usually filed _____.


_____ 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.



The CMS-1500 is made obsolete when using electronic claims submission.


Electronic claims submission software programs edit insurance claims data for accuracy.


A pattern of coding errors can trigger an investigation of fraud or abuse.


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.

electronic claim

A(n) _____ is submitted to the insurance carrier via the Internet.


A(n) _____ distributes claims to the appropriate insurance carrier.


The _____ electronic claims submission method allows the provider to communicate directly with the insurance company.


_____ 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.

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