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Claims Processing


Medicare Federally funded health ins provided to people age 65 or older, people younger than 65 who have certain disabilities, & people of all ages w/ end-stage kidney disease. Funded & administered at the national level
Medicaid Gov- based health ins option that pays for medical assist. for individuals who have low income & limited financial resources. Administered at the state level
Claims Are a complete record of the services provided by the health care professional, along w/ appropriate ins info
Transmitting Claims Involves sending required info to 3rd party payers for reimbursement
Administration Simplification Compliance Act (ASCA) Part of HIPAA, mandated the health care claims be submitted electronically
For institutional claims The "Through" date is used to determine the DOS
For professional claims The "From" data is used to determine the DOS
Timely Filing Requirement Within 1 calendar year of a claim's DOS
Electronic Data Interchange (EDI) The transfer of electronic info in a standard format
Primary Insurance Pays first, up to the limits of its coverage
Secondary Insurance If there are costs that the primary ins didn't cover, the bill goes to the secondary ins. The secondary ins, which can be Medicare, might not pay all the costs
Coordination of Benefits Determines which ins. plan is primary & which is secondary
Conditional Payment Medicare payment that is recovered after primary ins. pays
Crossover Claim Claim submitted by people covered by a primary & secondary ins. plan
Causes of Claim Transmission Errors Differences in a pt's name or its spelling, Missing or invalid pt identification number, invalid dates of services
Clean Claim Claim that's accurate & complete. They have all the info needed for processing
Dirty Claim Claim that is inaccurate, incomplete or contains other errors
Assignment of Benefits Contract in which the provider directly bills the payer & accepts the allowable charge
Allowable Charge The amt. an insurer will accept as full payment, minus applicable cost sharing
Medicare Administrative Contractor (MAC) Processes Medicare parts A & B claims from hospitals, physicians & other providers
Remittance Advice (RA) Report sent from the third-party payers to the provider that reflect any changes made to the original billing
Member Info (Claim form) Fields 1-13 focus on basic info about the pt, the insured ( if that person is not the pt).
Rendering Provider Field 14-33 include info about the providers, services rendered, diagnosis made, procedures performed, & modifiers needs
Explanation of Benefits (EOB) Describes the services rendered, payment, covered, & benefits, limits & denials
National Provider Identifier (NPI) Unique 10- digit code for providers required by HIPAA
Health Maintenance Organization (HMO) Plan that allows pts to only go to physicians, other health care professionals, or hospitals on a list of approved providers except in a emergency
Procedure Code ICD procedure codes (ICD-9-CM volume 3 or ICD-10-PCS), Current Procedural Terminology (CPT) codes of the Healthcare Common Procedures Coding System(HCPCS)
Modifier Additional info about types of services & part of valid CPT or HCPCS codes
2 items of info that need to be a claim? Name & DOB
What is a NPI number? Unique 10 digit for all providers under HIPAA
You are allowed to use both 6 or 8 digit for date one the claim (T or F)? TRUE
Describe when Medicare is the secondary ins. for a pt? When the pt has a group health ins plan, is covered by workers comp., or is on disability
Created by: diasiar