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claims processing_2

claims processing/compliance

QuestionAnswer
Employer Identification Number (EIN) Unique identifier issued by the Internal Revenue Service (IRS) for employers as required by HIPAA Electronic Health Care Transactions and Code Sets
First Party The insured
Guarantor The party responsible for payment of services provided
HIPAA Electronic Health Care Transactions and Code Sets HIPAA standardization of electronic transactions of health care data, including data elements, standard code sets, unique health identifiers, security safeguards, and privacy standards
HIPAA National Identifiers Required identification systems for health care organizations and health care providers
HIPAA Privacy Rule HIPAA national standards that protect individuals' medical records and other personal health information; covers the use and disclosure of PHI
HIPAA Security Rule Requires health care providers to establish safeguards ensuring the protection of PHI whenever transmitting any type of patient information via electronic transmission
HIPAA X12 837 (Health Care Claim or Equivalent Encounter Information) HIPAA mandated electronic transaction standard for claims, usually called the 837 claim or the HIPPA claim
Incomplete Claim Status Claim status indicating a claim is missing required information
Insurance Carrier the company that issues and assumes the risk of an insurance policy
Invalid Claim Status Claim status indicating a claim contains complete information, but the information may be incorrect and cannot be processed by the carrier
Manual Billing CMS-1500 is completed by hand and submitted for processing
Minimum necessary The HIPAA Privacy Rule stipulates that covered entities limit the amount of information disclosed to the minimum necessary to achieve the specified goal
National Provider Identifier (NPI) Unique identifier issued by the CMS as the standard of identification for health care providers
National Uniform Claim Committee (NUCC) Led by the American Medical Association (AMA) and determines the content of CMS-1500 claim forms
Created by: tina.reynolds