Question 1

HIPAA X12 837 Health Care Claim

Accepted Answer

Professional (837P) electronic formed used to send claims for physician services to primary and secondary payers

Question 2

CMS-1500

Accepted Answer

Paper claim form for physician services

Question 3

National Uniform Claim Committee (NUCC)

Accepted Answer

Organization responsible for claim content

Question 4

CMS-1500 (02/12)

Accepted Answer

Current paper claim form approved by the NUCC

Question 5

5010A1 Version

Accepted Answer

Newest format for EDI transactions

[TIP: have the billing address (provider's) street address not PO Box or a lock box]

Question 6

Carrier Block

Accepted Answer

Date entry area in the upper right portion of the CMS-1500

Question 7

Condition Code

Accepted Answer

Two-digit numeric or alphanumeric code used to report a special condition or unique circumstance

Question 8

Qualifier

Accepted Answer

Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI)

Question 9

Signature on File

Accepted Answer

Make sure that certain release information have within 12 month signature on file or SOF

Question 10

Billing Provider

Accepted Answer

Provider of healths services reported on a claim

Question 11

Pay-to Provider

Accepted Answer

Entity that will receive payment for a claim

Question 12

Rendering Provider

Accepted Answer

Healthcare professional who provides health services reported on a claim

Question 13

Other ID Number

Accepted Answer

Additional provider identification number

Question 14

Outside Laboratory

Accepted Answer

Purchased laboratory services

Question 15

Complaint Claims Require Diagnosis Codes [TIP]

Accepted Answer

A claim that does NOT report at least one diagnosis code will be denied

Question 16

Primary Diagnosis Codes [TIP]

Accepted Answer

An external cause code CANNOT be used as a primary diagnosis 
[some Z codes are allowed only as secondary diagnosis]

Question 17

ICD Indicator [TIP]

Accepted Answer

Check to confirm that the NUCC Guidelines for this IN remain in place for future years

Question 18

Service Line Information

Accepted Answer

Information about procedures performed for the patient

Question 19

Date of Service [TIP]

Accepted Answer

Dates for the same patient that fall in different years must be reported on separate claims

Question 20

Place of Service (POS) Code

Accepted Answer

Administrative code indicating where medical services were provided

Question 21

Administrative Code Set

Accepted Answer

Required codes for various data elements

Question 22

Healthcare Provider Taxonomy Code (HPTC)

Accepted Answer

Administrative code set used to report a physician's specialty

Question 23

Data Element

Accepted Answer

Smallest unit of information in a HIPAA transaction

Question 24

Required Data Element

Accepted Answer

Information that must be supplied on an electronic claim

Question 25

Situational Data Element

Accepted Answer

Information that must be on a claim in conjunction with certain other data elements

Question 26

Responsible Party

Accepted Answer

Other person or entity who will pay a patient's charges

Question 27

Claim Filing Indicator Code

Accepted Answer

Administrative code that identifies the type of health plan

Question 28

Individual Relationship Code

Accepted Answer

Administrative code specifying the patient's relationship to the subscriber

Question 29

Destination Payer

Accepted Answer

Health plan receiving a HIPAA claim

Question 30

Claim Control Number

Accepted Answer

Unique number assigned to a claim by the sender

Question 31

Claim Frequency Code (Claim Submission Reason Code)

Accepted Answer

Administrative code that identifies the claim as original, replacement, or void/cancel action

Question 32

Line Item Control Number

Accepted Answer

Unique number assigned by the sender to each service line item reported

Question 33

Claim Attachment

Accepted Answer

Documentation a provider sends a payer to support a claim

Question 34

Clean Claim

Accepted Answer

Claim accepted by a health plan for adjudication

Question 35

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response

Accepted Answer

Electronic format used to ask papers about claims

Question 36

Claim Scrubber

Accepted Answer

Software that checks claims to permit error correction 
[editing software]

Question 37

Upper Portion of the CMS-1500 Claim Form

Accepted Answer

Asks for information based on the patient information form, insurance card, and payer verification data

Question 38

Types of Providers [1]

Accepted Answer

It is common to have a physician practice as the pay-to provider--> the entity that is paid

Question 39

Types of Providers [2]

Accepted Answer

A rendering provider is the doctor who provides care for the patient and is a member of the physician practice that gets the payment

Question 40

Types of Providers [3]

Accepted Answer

Practices may use a billing service or a clearinghouse to transmit claims, which is identified as a separate nilling provider

Question 41

Types of Providers [4]

Accepted Answer

A physician who has sent a patient to another provider needs to be identified as the referring provider

Question 42

Lower Portion of CMS-1500 Claim Form

Accepted Answer

Contains information about the provider or supplier and the patient's condition including the diagnosis, procedures, and charges

Question 43

Hierarchy of Data Elements on the HIPAA 837P Claim

Accepted Answer

Required data elements must be provided on the claim and accepted by a payer

Question 44

The HIPAA 837P Claim Transaction [1]

Accepted Answer

Provider Information---Claim filing indicator code

Question 45

The HIPAA 837P Claim Transaction [2]

Accepted Answer

Subscriber Information---Individual relationship code

Question 46

The HIPAA 837P Claim Transaction [3]

Accepted Answer

Payer Information---Claim control number

Question 47

The HIPAA 837P Claim Transaction [4]

Accepted Answer

Claim Information---Claim submission reason code

Question 48

The HIPAA 837P Claim Transaction [5]

Accepted Answer

Service Line Information---Line item control number

Question 49

Electronic Claim Transmission [1]

Accepted Answer

In the direct transmission approach, providers and payers exchange transactions directly without using a clearinghouse

Question 50

Electronic Claim Transmission [2]

Accepted Answer

The majority of providers use clearinghouses to send and receive data in correct EDI format

Question 51

Electronic Claim Transmission [3]

Accepted Answer

Some payers offer online DDE to providers, which involves using an Internet-based service into which employees key the standard data elements

Question 52

Group Health Plan (GHP)

Accepted Answer

Plan of an employer or employee organization to provide healthcare to employees or their families 

[Retired Employee---the group is "policyholder']

Question 53

Rider

Accepted Answer

Document modifying an insurance contract 
[also called "options"---an additional plan--aren't included on contract]

Question 54

Carve Out

Accepted Answer

Part of a standard health plan changed under an employer-sponsored plan

Question 55

Open Enrollment Period

Accepted Answer

Time when a policyholder selects from offered benefits

[Plans to choose---once a year]

Question 56

Federal Employees Health Benefits (FEHB) Program

Accepted Answer

Covers employees and retirees (and their families) of the federal government 

[Largest employer sponsored in the U.S.--- Administered by OPM)

Question 57

Employee Retirement Income Security Act of 1974 (ERISA)

Accepted Answer

Law providing incentives & protection for companies with employee health and pension plans 
[Assumed there own risks---run by DOL]

Question 58

Summary Plan Description (SPD)

Accepted Answer

Document that shows you your rights and benefits

Question 59

Third-party Claims Administrator (TPA)

Accepted Answer

Business associate of health plan---involved with the plan

[work in getting the claims paid]

Question 60

Administration Services Only (ASO)

Accepted Answer

Contract under which a third-party administrator provides administrative services to an employer for a fixed fee per employee

Question 61

Section 125 Cafeteria Plan

Accepted Answer

Employer's health plans structured to permit funding of premiums with pretax payroll deductions 

[Different types of plans--options]

Question 62

Waiting Period

Accepted Answer

Amount of time that mist pass before an employee/department may enroll in a health plan 

[depending how long you wait 1 day, weeks, months]

Question 63

Late Enrollee

Accepted Answer

Category of enrollment that may have different eligibility requirement 

[After open-enrollment you get hired]

Question 64

Individual Deductible

Accepted Answer

Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits begin 

[one person]

Term	Definition
HIPAA X12 837 Health Care Claim	Professional (837P) electronic formed used to send claims for physician services to primary and secondary payers
CMS-1500	Paper claim form for physician services
National Uniform Claim Committee (NUCC)	Organization responsible for claim content
CMS-1500 (02/12)	Current paper claim form approved by the NUCC
5010A1 Version	Newest format for EDI transactions [TIP: have the billing address (provider's) street address not PO Box or a lock box]
Carrier Block	Date entry area in the upper right portion of the CMS-1500
Condition Code	Two-digit numeric or alphanumeric code used to report a special condition or unique circumstance
Qualifier	Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI)
Signature on File	Make sure that certain release information have within 12 month signature on file or SOF
Billing Provider	Provider of healths services reported on a claim
Pay-to Provider	Entity that will receive payment for a claim
Rendering Provider	Healthcare professional who provides health services reported on a claim
Other ID Number	Additional provider identification number
Outside Laboratory	Purchased laboratory services
Complaint Claims Require Diagnosis Codes [TIP]	A claim that does NOT report at least one diagnosis code will be denied
Primary Diagnosis Codes [TIP]	An external cause code CANNOT be used as a primary diagnosis [some Z codes are allowed only as secondary diagnosis]
ICD Indicator [TIP]	Check to confirm that the NUCC Guidelines for this IN remain in place for future years
Service Line Information	Information about procedures performed for the patient
Date of Service [TIP]	Dates for the same patient that fall in different years must be reported on separate claims
Place of Service (POS) Code	Administrative code indicating where medical services were provided
Administrative Code Set	Required codes for various data elements
Healthcare Provider Taxonomy Code (HPTC)	Administrative code set used to report a physician's specialty
Data Element	Smallest unit of information in a HIPAA transaction
Required Data Element	Information that must be supplied on an electronic claim
Situational Data Element	Information that must be on a claim in conjunction with certain other data elements
Responsible Party	Other person or entity who will pay a patient's charges
Claim Filing Indicator Code	Administrative code that identifies the type of health plan
Individual Relationship Code	Administrative code specifying the patient's relationship to the subscriber
Destination Payer	Health plan receiving a HIPAA claim
Claim Control Number	Unique number assigned to a claim by the sender
Claim Frequency Code (Claim Submission Reason Code)	Administrative code that identifies the claim as original, replacement, or void/cancel action
Line Item Control Number	Unique number assigned by the sender to each service line item reported
Claim Attachment	Documentation a provider sends a payer to support a claim
Clean Claim	Claim accepted by a health plan for adjudication
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response	Electronic format used to ask papers about claims
Claim Scrubber	Software that checks claims to permit error correction [editing software]
Upper Portion of the CMS-1500 Claim Form	Asks for information based on the patient information form, insurance card, and payer verification data
Types of Providers [1]	It is common to have a physician practice as the pay-to provider--> the entity that is paid
Types of Providers [2]	A rendering provider is the doctor who provides care for the patient and is a member of the physician practice that gets the payment
Types of Providers [3]	Practices may use a billing service or a clearinghouse to transmit claims, which is identified as a separate nilling provider
Types of Providers [4]	A physician who has sent a patient to another provider needs to be identified as the referring provider
Lower Portion of CMS-1500 Claim Form	Contains information about the provider or supplier and the patient's condition including the diagnosis, procedures, and charges
Hierarchy of Data Elements on the HIPAA 837P Claim	Required data elements must be provided on the claim and accepted by a payer
The HIPAA 837P Claim Transaction [1]	Provider Information---Claim filing indicator code
The HIPAA 837P Claim Transaction [2]	Subscriber Information---Individual relationship code
The HIPAA 837P Claim Transaction [3]	Payer Information---Claim control number
The HIPAA 837P Claim Transaction [4]	Claim Information---Claim submission reason code
The HIPAA 837P Claim Transaction [5]	Service Line Information---Line item control number
Electronic Claim Transmission [1]	In the direct transmission approach, providers and payers exchange transactions directly without using a clearinghouse
Electronic Claim Transmission [2]	The majority of providers use clearinghouses to send and receive data in correct EDI format
Electronic Claim Transmission [3]	Some payers offer online DDE to providers, which involves using an Internet-based service into which employees key the standard data elements
Group Health Plan (GHP)	Plan of an employer or employee organization to provide healthcare to employees or their families [Retired Employee---the group is "policyholder']
Rider	Document modifying an insurance contract [also called "options"---an additional plan--aren't included on contract]
Carve Out	Part of a standard health plan changed under an employer-sponsored plan
Open Enrollment Period	Time when a policyholder selects from offered benefits [Plans to choose---once a year]
Federal Employees Health Benefits (FEHB) Program	Covers employees and retirees (and their families) of the federal government [Largest employer sponsored in the U.S.--- Administered by OPM)
Employee Retirement Income Security Act of 1974 (ERISA)	Law providing incentives & protection for companies with employee health and pension plans [Assumed there own risks---run by DOL]
Summary Plan Description (SPD)	Document that shows you your rights and benefits
Third-party Claims Administrator (TPA)	Business associate of health plan---involved with the plan [work in getting the claims paid]
Administration Services Only (ASO)	Contract under which a third-party administrator provides administrative services to an employer for a fixed fee per employee
Section 125 Cafeteria Plan	Employer's health plans structured to permit funding of premiums with pretax payroll deductions [Different types of plans--options]
Waiting Period	Amount of time that mist pass before an employee/department may enroll in a health plan [depending how long you wait 1 day, weeks, months]
Late Enrollee	Category of enrollment that may have different eligibility requirement [After open-enrollment you get hired]
Individual Deductible	Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits begin [one person]
Family Deductible	Fixed, periodic amount that must be met by the combines payments of an insured/dependent group before benefits begin [more than one family]
Tiered Network	Network system that reimburses more quality, cost-effective providers [pays more for quality]
Formulary	List of plan's approval drugs and their proper dosages [a document that goes with prescription]
Consolidated Omnibus Budget Reconciliation Act (COBRA)	a law that requires employers with more than 20 employees to allow terminated employees get pay for coverage for 18 months [you get fired/quite--->you can still get paid and insured]
Parity	equality with medical/surgical benefits
Narrow Network	Payer network of physicians and hospitals with limited choices fro patients
Preferred Provider Organization (PPO)	the most popular type of private plan, followed by health maintenance organizations (HMOs), especially the point-of-service (POS) variety.
Discounted Fee-for-service Structure	A payment schedule for services based on a reduced percentage of usual charges
Health Maintenance Organizations (HMO)	is licensed by the state---has the most stringent guidelines and the narrowest choice of providers
Open-panel	Any physician that meets the HMO standards
Closed-panel	Physician are either HMO employees or belong to HMO
Subcapitation	Arrangement by a captivated provider prepays an ancillary provider [per member per month fee]
Episode-of-care (EOC) Option	Flat service by a health plan to a provider for a defined set of services
Independent (or individual) Practice Association (IPA)	HMO in which physicians are self-employed and provide services to members and nonmembers
Medical Home Model	Care plans that emphasizes primary care with coordinated care which involves communications among patient's physicians [PCP--coordinate care (reference) payed for how patients ar going]
High-deductible Health Plan (HDHP)	A health plan that combines high-deductible insurance and funding option to pay for patients' out-of-pocket expenses up to deductible
Health Reimbursement Account (HRA)	Consumer-driven health plan finding option that requires an employer to set aside annual amount for healthcare costs [Set-up by employer]
Health Savings Account (HSA)	A health plan funding options are under funds that are set aside to pay certain healthcare [roll over--set up by employer (its yours)]
Flexible Savings (spending) Account (FSA)	Health plan funding option that has employer and employee contributions---money left goes to the employers unless employee uses it. [employee & employers more flexible]
Major national payers	1] Anthem (biggest payer) 2] United Health Group 3] Aetna 4] Kaiser Permanente
BlueCross BlueShield Association (BCBS)	A national healthcare licensing association
Pay-for-performance (P4P)	Patients that are doing/going well get money
Blue Card	People who travel (are away from local area)
Host Plan	Participating provider's local BCBS plan [Local Plan]
Home Plan	BCBS Plan in the subscriber's community [Local Plan]
Flexible Blue	BCBS consumer driven health plan
Individual Health Plans (IHP)	Medical insurance plan purchased by an individual [more expensive]
Health Insurance Exchange (HIX)	Government-regulated marketplace offering insurance plans to individuals
Metal Plans	Health plans created by the ACA named after different types of metals [Bronze, silver, gold, and platinum---> all must have Health Benefits]
Essential Health Benefits (EHB)	Required benefits that must be offered by metal plans as well as some other insurance plans [ex: maternity care, laboratory test, and emergency services]
Participation Contracts	There are 5 main parts
Utilization Review	Payer's process for determining medical necessity
Stop-loss Provision	Protection against large losses or severely adverse claims experience
Precertification	preauthorization for hospital admission or outpatient procedures
Silent PPO	An agreement with no document needed
Elective Surgery	Non-emergency surgical procedure
Utilization Review Organization (URO)	Organization hired by a payer to evaluate medical necessity
What specified time should providers notify plans about emergency surgeries after the procedure	48-72 hours
Plan Summary Grid	Quick-reference table for health plans: -summarizes key items from the contract
THE STEPS FOR REVENUE CYCLE [1]	Pre-register patients
THE STEPS FOR REVENUE CYCLE [2]	Establish Financial responsibility for visit
THE STEPS FOR REVENUE CYCLE [3]	Check in patient
THE STEPS FOR REVENUE CYCLE [4]	Review coding compliance
THE STEPS FOR REVENUE CYCLE [5]	Check billing compliance
THE STEPS FOR REVENUE CYCLE [6]	Check out patient
THE STEPS FOR REVENUE CYCLE [7]	Prepare and transmit claims
Repricer	Vendor that sets up fee schedule and discounts and processes a payer's
Office of Worker's Compensation Programs (OWCP)	Entity that administers programs to cover work-related illnesses or injuries suffered y civilian employees of federal agencies -procide medical treatment, cash benefits for lost wages, vocational rehabilitation
Federal Employees' Compensation Act (FECA)	Law that provides workers' compensation insurance for civilian employees of the federal government
Occupational Safety and Health Administration (OSHA)	Organization created to protect workers from health and safety risks on the job [toxic fumes, faulty machinery, and excess noise]m
Two types of workers' compensation benefits	1]Medical expenses which result from work-related illness/injury 2] Lost wages while the worker is unable to work
Employers often obtain workers' compensation insurance from:	-A state workers' compensation fund (companies pay premiums into funds) -Self-insured find -Private Plan
Occupational Disease or Illness	Physical condition caused by the work environment over a period longer than one workday or shift
Final Report	Document filed by the physician in a state workers' compensation case when the patient is discharged [before returning to work]
Independent Medical Examination (IME)	Examination conducted by a physician to conform that an individual is permanently disabled
Vocational Rehabilitation	Program to prepare a patient for reentry into the workforce
Pain Terminology	-Minimal -Severe -Slight -Moderate
Disability Terminology	-Limitation to light work -Precluding heavy work -Limitation to sedentary work
HIPAA Privacy Rule	(workers' compensation) PHI may be disclosed to employer without patient's authorization
Workers' Compensation Diagnosis Coding	Diagnosis doing must be included external cause codes (secondary never primary)
Physician of Record	Provider who first treats a patient and assesses the level of disability
Progress Report	Document filed by the physician in state workers' compensation cases when a patient's medical condition or disability changes
First Report of Injury	Document filled in state workers' compensation cases, containing employer and accident information and patient's description of the accident [employer or physician must file within a certain time period]
Admission of Liability	Determination that an employer is responsible for an employee's claim under workers' compensation [states employer is responsible for the injury]
Notice of Contest	Notification of determination to deny liability for an employee's workers' compensation claim [Denies employer liability]
Disability Compensation Program	A plan that provides partial reimbursement for lost income when a disability prevents an individual from working
Supplemental Security Income (SSI)	Program that helps pay living expenses for low-income older people and those whoa re blind or have disabilities
Social Security Disability Insurance (SSDI)	Federal disability compensation program for some qualified people
Federal Insurance Contribution Act (FICA)	Law that authorizes payroll deductions for the social security disability program
Preparing Disability Reports	Abstract information from the patient's medical record
Automobile Insurance Policy	Contract between an insurance company and an individual for which they pay a premium in exchange for coverage of specified motor vehicle-related financial losses
Personal Injury Protection (PIP)	Insurance coverage for medical expenses and other expenses related to a motor vehicle accident
Subrogation	Action by payer to recoup expenses for a claim it paid when another party should have been responsible for paying at least a portion of the claim
Lien	Written, legal claims on property to secure debut payment

MEAS 137 CH. 7, 8,12

Includes chapters 7, 8, 12

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