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Claims Process_1

QuestionAnswer
Adjudication The process health plans follow to examine and determine payment
Audit A review or formal examination of a provider's accounting or patient's medical records
Carrier Block Data entry area located in the upper right corner of the CMS-1500 that allows for a four-line address for the payer
Clearinghouse Edits and routes electronic claims to the insurance carrier for payment
CMS-1500 Claim form used to submit paper claims for services and procedures rendered by physicians and other health care professionals on an outpatient basis
Continuity of Care coordinating treatment and health services between patients' health care providers
Covered Entities Health plans, health care clearinghouses, or health care providers that conduct health information in electronic form in connection with a transaction covered by HIPAA
Denied claim status Claim status indicating a claim has been processed, but contained incorrect or incomplete information; a claim may also be denied for medical neccesity
Durable Medical equipment (DME) "equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose; generally not useful to a person in absence of illness or injury; appropriate for use in the home." AKA prosthetics, orthotics, & supplies (DMEPOS).
Electronic billing the process of submitting medical claims electronically to an insurance carrier for reimbursement of services rendered by a health care provider
Electronic data interchange (EDI) A secure system-to-system interchange of data in a standardized format
Eligibility verification Conformation that the patient is entitled to benefits by verifying the name of the insurance carrier, the effective date of active coverage, policy information, group number, copayments, & deductible; typically performed before services are rendered
Created by: tina.reynolds