CMS - EDI
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| when to bill NO charges | always bill NO charges
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| entering data for OCR claims | capital letters, no punctuation, procedure & diagnotic codes, leave blocks blank that do not apply
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| when do you submit documentation | only when requested
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| how are paper claims submitted | on paper, through the mail, and then optically scanned
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| how are electronic claims submitted | through the internet
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| agreement for electronic claims submission | signed agreement by the physician & carrier
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| funtions of a clearinghouse | known as TPA (third party administrator), software edit checks, sorts and transmits claims, and receives the ERA back from the insurance company
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| NEIC systems | provides national network that allows physcians to use one version to communicate; also known as the clearinghouse
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| provider number used on the insurance claim form | NPI (national provider identification)
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| two ways claims can be transmitted electronically | 1. carrier direct (from doctor directly to insurance company) 2. clearinghouse
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| dual coverage | patient has 2 private insurance policies
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| where is insurance companies name and address listed on the claim form | top right hand side
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| two sections of a claim form | 1. patient insured (top half) 2. physcian and supplier (bottom half)
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| how many locations for diagnostic codes can be listed on the claim form | 4
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| digital signature | indicates a signature has been attached from within the software application
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| networks | computers that are interconnected to exchange information
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| clearinghouse | entity that receives transmissions of claims from the physcian office
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| rejected claim | claim that needs further clarification, possible investigation, and answers to questions
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| clean claim | claim submitted with the program or policy time limit and contains all necessary information
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| pending claim | claim held in suspense while being reviewed or additional information is requested
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| incomplete claim | claim missing information
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| CMS-1500 | universal claim form
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