Question 1

Administrative Code Set

Accepted Answer

Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.

Question 2

Billing provider

Accepted Answer

The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to provider who receives payment.

Question 3

Carrier block

Accepted Answer

Data entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer.

Question 4

Claim attachment

Accepted Answer

Documentation that a provider sends to a payer in support of a healthcare claim.

Question 5

Claim Control Number

Accepted Answer

Unique number assigned to a healthcare claim by the sender.

Question 6

Claim filing indicator code

Accepted Answer

Administrative code used to identify the type of health plan.

Question 7

Claim Frequency Code (Claim Submission reason code)

Accepted Answer

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

Question 8

Claim Scrubber

Accepted Answer

Software that checks claims to permit error correction for clean claims.

Question 9

Clean Claim

Accepted Answer

A claim that is accepted by a health plan for adjudication.

Question 10

CMS-1500

Accepted Answer

Paper claim for physician services.

Question 11

CMS-1500 (02/12)

Accepted Answer

Current paper claim approved by the NUCC.

Question 12

Condition Code

Accepted Answer

Two-digit numeric or alphanumeric code used to report a special condition or unique circumstance about a claim; reported in Item Number 10d on the CMS-1500 claim form.

Question 13

Data element

Accepted Answer

The smallest unit of information in a HIPAA transaction.

Question 14

Destination Payer

Accepted Answer

In HIPAA claims, the health plan receiving the claim.

Question 15

Healthcare Provider Taxonomy Code (HPTC)

Accepted Answer

Administrative code set used to report a physician’s specialty.

Question 16

HIPAA  X12  837 Health Care Claim: Professional (837P)

Accepted Answer

Generic term for the HIPAA X12N 837 professional healthcare claim transaction.

Question 17

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

Accepted Answer

The HIPAA X12N 276/277 transaction in which a provider asks a health plan for information on a claim’s status and receives an answer from the plan.

Question 18

Individual Relationship Code

Accepted Answer

Administrative code that specifies the patient’s relationship to the subscriber (insured).

Question 19

Line item control number

Accepted Answer

On a HIPAA claim, the unique number assigned by the sender to each service line item reported.

Question 20

National Uniform Claim Committee (NUCC)

Accepted Answer

Organization responsible for the content of healthcare claims.

Question 21

Other ID number

Accepted Answer

Additional provider identification number supplied on a healthcare claim.

Question 22

Outside Laboratory

Accepted Answer

Purchased laboratory services.

Question 23

Pay-to provider

Accepted Answer

The person or organization that is to receive payment for services reported on a HIPAA claim; may be the same as or different from the billing provider.

Question 24

Place of service (POS) code

Accepted Answer

HIPAA administrative code that indicates where medical services were provided.

Question 25

Qualifier

Accepted Answer

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

Question 26

Rendering Provider

Accepted Answer

Term used to identify the physician or other medical professional who provides the procedure reported on a healthcare claim if other than the pay-to provider.

Question 27

Required Data Element

Accepted Answer

Information that must be supplied on an electronic claim.

Question 28

Responsible Party

Accepted Answer

Person or entity other than the insured or the patient who will pay a patient’s charges.

Question 29

Service Line information

Accepted Answer

On a HIPAA claim, information about the services being reported.

Question 30

Situational Data Element

Accepted Answer

Information that must be supplied on a claim when certain other data elements are provided.

Billing and Coding

Chapter 7 Terms

Question	Answer
5010A1 Version
Administrative Code Set	Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.
Billing provider	The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to provider who receives payment.
Carrier block	Data entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer.
Claim attachment	Documentation that a provider sends to a payer in support of a healthcare claim.
Claim Control Number	Unique number assigned to a healthcare claim by the sender.
Claim filing indicator code	Administrative code used to identify the type of health plan.
Claim Frequency Code (Claim Submission reason code)	Administrative code that identifies the claim as original, replacement, or void/cancel action.
Claim Scrubber	Software that checks claims to permit error correction for clean claims.
Clean Claim	A claim that is accepted by a health plan for adjudication.
CMS-1500	Paper claim for physician services.
CMS-1500 (02/12)	Current paper claim approved by the NUCC.
Condition Code	Two-digit numeric or alphanumeric code used to report a special condition or unique circumstance about a claim; reported in Item Number 10d on the CMS-1500 claim form.
Data element	The smallest unit of information in a HIPAA transaction.
Destination Payer	In HIPAA claims, the health plan receiving the claim.
Healthcare Provider Taxonomy Code (HPTC)	Administrative code set used to report a physician’s specialty.
HIPAA X12 837 Health Care Claim: Professional (837P)	Generic term for the HIPAA X12N 837 professional healthcare claim transaction.
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response	The HIPAA X12N 276/277 transaction in which a provider asks a health plan for information on a claim’s status and receives an answer from the plan.
Individual Relationship Code	Administrative code that specifies the patient’s relationship to the subscriber (insured).
Line item control number	On a HIPAA claim, the unique number assigned by the sender to each service line item reported.
National Uniform Claim Committee (NUCC)	Organization responsible for the content of healthcare claims.
Other ID number	Additional provider identification number supplied on a healthcare claim.
Outside Laboratory	Purchased laboratory services.
Pay-to provider	The person or organization that is to receive payment for services reported on a HIPAA claim; may be the same as or different from the billing provider.
Place of service (POS) code	HIPAA administrative code that indicates where medical services were provided.
Qualifier	Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI).
Rendering Provider	Term used to identify the physician or other medical professional who provides the procedure reported on a healthcare claim if other than the pay-to provider.
Required Data Element	Information that must be supplied on an electronic claim.
Responsible Party	Person or entity other than the insured or the patient who will pay a patient’s charges.
Service Line information	On a HIPAA claim, information about the services being reported.
Situational Data Element	Information that must be supplied on a claim when certain other data elements are provided.

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