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MED 112
Chapter 7 Terms
| Question | Answer |
|---|---|
| HIPAA X12 837 Health Care Claim: Professional (837P) | The form used to send a claim for physician services to both primary and secondary payers |
| CMS-1500 | Paper claim for physician services |
| National Uniform Claim Committee (NUCC) | Organization responsible for the content of healthcare claims |
| CMS-1500 (02/12) | Current paper claim approved by the NUCC |
| 5010A1 version | Under HIPAA, the newest format for EDI transactions to accommodate ICD-10-CM codes and additional data |
| INs | Item Numbers (33) |
| carrier block | Data entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer |
| 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 |
| qualifier | Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI) |
| 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 |
| 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 |
| 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 |
| other ID number | Additional provider identification number supplied on a healthcare claim |
| outside laboratory | Purchased laboratory services |
| Service line information | On a HIPAA claim, information about the services being reported- procedures performed for the patient |
| place of service (POS) code | HIPAA administrative code that indicates where medical services were provided |
| administrative code set | Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes |
| Healthcare Provider Taxonomy Code (HPTC) | Administrative code set used to report a physician’s specialty |
| data element | The 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 supplied on a claim when certain other data elements are provided |
| responsible party | Person or entity other than the insured or the patient who will pay a patient’s charges |
| claim filing indicator code | Administrative code used to identify the type of health plan |
| individual relationship code | Administrative code that specifies the patient’s relationship to the subscriber (insured) |
| destination payer | In HIPAA claims, the health plan receiving the claim |
| claim control number | Unique number assigned to a healthcare 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 | On a HIPAA claim, the unique number assigned by the sender to each service line item reported |
| Claim attachment | Documentation that a provider sends to a payer in support of a healthcare claim |
| Clean claim | A claim that is accepted by a health plan for adjudication |
| HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277) | The standard electronic transaction to obtain information on the status of a claim |
| Claim scrubber | Software that checks claims to permit error correction for clean claims |
| Patient Information | Insurer's ID number |
| Claim Codes | Condition codes |
| FECA Number | Nine-digit alphanumeric identifier assigned to a patient who is an employee of the federal government claiming work-related condition(s) |
| DN | Qualifier for referring provider |
| 1G | Provider UPIN number |
| ICD Indicator "0" | ICD-10 codes utilized |
| Resubmission code "8" | Void prior claim |
| POS code | Facility type code |
| Place of Service code "31" | Skilled nursing facility |
| Federal Tax ID number | Employer Identification Number |
Created by:
Felicia26