Electronic Data Interchange
Terms in this set (59)
The exchange of data in a standardized format through computer systems is known as electronic data interchange (EDI).
Encrypted data often looks like gibberish to unauthorized users.
Even if a physician's office does not bill Medicare and does not submit transactions electronically, directly, or through a third party, the practice is still subject to HIPAA transaction rules.
A group of insurance claims sent at the same time from one facility is known as a
Insurance claims transmitted electronically are usually paid in
2 weeks or less
Insurance claims completed manually are usually paid in
4-6 weeks on average.
Advantages of electronic claims submission are
audit trail as proof of receipt.
online error-edit process.
quicker submission of corrected and additional data.
A clearinghouse is a/an
entity that receives transmission of insurance claims, separates the claims, performs software edits, and transmits claims to the insurance payer.
CMS's electronic medical claims is used for nearly all medicare transactions, including claims submission, payment, direct deposit, online eligibility verification, coordination of benefits, and claims status.
The objectives of the HIPAA Transaction and Code Set (TCS) Rule are:
to achieve a higher quality of care.
to reduce administration cost.
Dr. Biltman has 12 full-time employees and submits paper claims to Medicare. His medical practice is considered a covered entity and therefore is required under HIPAA to convert to electronic transactions.
Dr. Maria Lopez has 5 full-time employees and submits claims only on paper to Medicare. Her practice is considered a covered entity and therefore is required to comply with HIPAA guidelines.
According to CMS, providers who are not small providers and must send all claims electronically in the HIPAA format are
institutional organizations with fewer than 25 full-time employees.
physicians with fewer than 10 full-time employees.
A medical code set is the allowable set of codes that anyone could use to enter into a specific space (field) on a form.
Data elements used uniformly to document why patients are seen (diagnosis, ICD-9-CM) and what is done to them during their encounter (procedure, CPT-4 and HCPCS) are
medical code sets.
The Standard Unique Identifier required by HIPAA to be used when submitting claims are
employer and health care provider.
health plan and patient.
The most important function of a practice management system (PMS) is accounts receivable.
Computer systems are free to use any data format when storing data because HIPAA standards apply only to the format in which data are transmitted.
Additional names for an encounter form include:
charge slip, patient service slip.
routing form, multipurpose billing form.
super bill, transaction slip.
Third-party payer's claims examiners and medicare are permitted to recode the codes input on the bill by the insurance billing specialist (IBS).
The physician's signature on the agreement or contract with the third-party payer is a substitute for the physician's signature on the claim form.
What is required for assignment of benefits?
Obtain each patient's signature
Retain each patient's signature in the office records
If a claim is denied or rejected, the insurance billing specialist should respond by
adding the missing, miscoded, or incomplete information.
correct the missing, miscoded, or incomplete information.
resubmit the claim
Direct data entry (DDE) via dial-up is the only method for getting claims submitted to either the payer or the clearinghouse.
When problems occur in electronic claims submission, usually a status report is received electronically from the third-party payer which indicates
assigned and unassigned claims.
crossed over and not crossed over claims.
claims accepted with errors and rejected claims
The three kinds of information system safeguards security measures are administrative, technical, and physical safeguards.
According to HIPAA a Confidentiallity Statement should include:
Written or oral disclosure of information pertaining to patients is prohibited.
Disclosure of information without consent of the patient results in serious penalty.
According to HIPAA reasonable safeguards are
Accepted standards that are implemented and periodically monitored to demonstrate office compliance.
Measurable solutions based on accepted standards.
Automated backup of keyboarded data should be performed preferably daily.
Acceptable methods, according to HIPAA, for properly erasing or destroying electronic protected health information (ePHI) and the hardware or electronic media on which it is stored include
reformat and overwrite the disk media several times
shred audiotapes, microfilm, or microfiche.
Back-and-forth communication between user and computer that occurs during online real time .
A combination of letters, numbers, or symbols that each individual is assigned to access the computer system
An online transaction concerning the status of an insurance claim.
electronic remittance advice
An internal audit that reviews who has access to protected health information (PHI).
An automatic log off that prevents unauthorized users from accessing a computer .
How the physician's office handles the retention, removal, and disposal of paper records.
The reasonable time to expect payment from a third-party payer after submission of a paper claim is
within 4 to 12 weeks
The reasonable time to expect payment from a third-party payer after submission of an electronically transmitted claim is
as little as 7 days
The document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as a/an
Explanation of Benefits (EOB).
Time limits stated in individual health insurance policies about an insurance company's obligation to pay benefits are the same for all insurance companies.
A suspended claim is one that is processed by a third-party payer but is held in an indeterminate (pending) state about payment either because of an error or the need for additional information from the provider of service or the patient.
Insurance claim register and tickler file are two claim management techniques used to track pending or resubmitted claims.
A follow-up effort made to an insurance company to locate the status of an insurance claim is called a/an
A written request made to an insurance company to locate the status of an insurance claim is often referred to as a/an
An insurance claim with an invalid procedure code.
An insurance claim for which the code description does not match services received.
An insurance claim for a service that has been bundled with other services.
An insurance claim for which prior approval was not obtained.
An insurance claim for which the services or procedure is not justified by diagnosis.
An insurance claim that was submitted but the insurance company says it has not received.
An insurance claim for which payment is overdue from a nonpayer.
According to the Office of the Inspector General (OIG), not returning overpayment promptly can lead to severe fines and implicate fraudulent activity.
If a claim has not been paid, you should not automatically rebill without researching the reason why it is still outstanding because
the insurance company may audit the physician's practice for trying to collect duplicate payment.
rebilling claims can be considered duplicate claims.
An appeal is a request for payment by asking for a review of an insurance claim that has been inadequately or incorrectly paid or denied by an insurance company.
An appeal on a claim should be based on
state and federal insurance laws and regulations.
The decision to appeal should be based on
sufficient information to back up the claim.
sufficient amount of money in question.
A peer review is an evaluation done by a group of unbiased practicing physicians to judge the effectiveness and efficiency of professional care rendered.
A level 1 Medicare re-determination (appeal) must be done in the presence of a Hearing Officer.
The insurance industry is protected by a special exemption from
Federal Trade Commission (FTC).
The FTC under the McCarron Act cannot attack unfair or deceptive practices if there is any state law about such practices.
Types of problems that should be submitted to the insurance commissioner include
delay in settlement of a claim, after proper appeal has been made.
illegal cancellation or termination of an insurance policy.
problems about insurance premium rates.
To speed up payments from an insurance company that is continually a slow payer, include a note informing the carrier that unless the claim is paid or denied within 30 days, a formal written complaint will be filed with
state insurance commissioner.
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