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Claims Processing
H.I.T
| Term | Definition |
|---|---|
| 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
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