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Chap 7/8
CMS - EDI
| Question | Answer |
|---|---|
| when to bill NO charges | always bill NO charges |
| entering data for OCR claims | capital letters, no punctuation, procedure & diagnotic codes, leave blocks blank that do not apply |
| when do you submit documentation | only when requested |
| how are paper claims submitted | on paper, through the mail, and then optically scanned |
| how are electronic claims submitted | through the internet |
| agreement for electronic claims submission | signed agreement by the physician & carrier |
| funtions of a clearinghouse | known as TPA (third party administrator), software edit checks, sorts and transmits claims, and receives the ERA back from the insurance company |
| NEIC systems | provides national network that allows physcians to use one version to communicate; also known as the clearinghouse |
| provider number used on the insurance claim form | NPI (national provider identification) |
| two ways claims can be transmitted electronically | 1. carrier direct (from doctor directly to insurance company) 2. clearinghouse |
| dual coverage | patient has 2 private insurance policies |
| where is insurance companies name and address listed on the claim form | top right hand side |
| two sections of a claim form | 1. patient insured (top half) 2. physcian and supplier (bottom half) |
| how many locations for diagnostic codes can be listed on the claim form | 4 |
| digital signature | indicates a signature has been attached from within the software application |
| networks | computers that are interconnected to exchange information |
| clearinghouse | entity that receives transmissions of claims from the physcian office |
| rejected claim | claim that needs further clarification, possible investigation, and answers to questions |
| clean claim | claim submitted with the program or policy time limit and contains all necessary information |
| pending claim | claim held in suspense while being reviewed or additional information is requested |
| incomplete claim | claim missing information |
| CMS-1500 | universal claim form |
Created by:
maxphia32
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