Busy. Please wait.
Log in with Clever

show password
Forgot Password?

Don't have an account?  Sign up 
Sign up using Clever

Username is available taken
show password

Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
Didn't know it?
click below
Knew it?
click below
Don't Know
Remaining cards (0)
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

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
Popular Medical sets




Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
restart all cards