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About Claims
| Definition | Answer |
|---|---|
| Review of claims for accuracy and completeness. | Auditing |
| A complete record of services provided by a health care professional, along with appropriate insurance information, submitted for reimbursement to a third-party provider. | Claim |
| Agency that converts claims into a standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards. | Clearinghouse |
| Basic billing reimbursement steps: | 1. Patient Information 2. Verify Insurance 3. Prepare encounter form 4. Code DX & CPT codes 5. Review Linkage Protocol 6. Calculate Physician's Charges 7. Prepare claim 8. Transmit claim 9. Follow up on reimbursement |
| Developed by AMA and CMS; used by physicians and other professionals to bill outpatient services and supplies to Tricare, Medicare, some Medicaid programs, and some private insurance managed care plans. | CMS 1500 Universal Claim Form |
| An insurance claim submitted on paper, including those optically scanned and converted to an electronic form by the insurance carrier. | Paper Claim/ CMS 1500 |
| An insurance claim submitted by computer. | Electronic Claim |
| Transmitting electronic medical insurance claims from providers, in standard format (837-P), to payers using the necessary information systems is called ______________. | Electronic Data Interchange (EDI) |
| A group that takes nonstandard medical billing software formats and translates them into the standard Electronic Data Interchange (EDI) formats is called a ________________. | Clearinghouse |
| A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment. | Dirty Claim |
| A completed insurance claim form submitted, without errors, within the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly. | Clean Claim |
| Authorization by a policyholder that allows a payer to pay benefits directly to provider. | Assignment of Benefits (Box 27 on CMS 1500 form) |
| A program set up by a health care provider to ensure compliance with regulations regarding coding and billing to prevent fraud and abuse. | Compliance Program |
| Review Linkage Protocol: | - Appropriateness of Codes - Payers rules about linkage - Documentation to support codes - Compliance with regulation and guidelines |
Created by:
cattomko
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