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For large providers that submit paper claims to Medicare & have 10 or more employees the provider is required to do what?
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In regards to HIPAA, a provider who sends claims electronically is required to meet what?
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Chapter 8 EDI
Electronic Data Interchange
| Question | Answer |
|---|---|
| For large providers that submit paper claims to Medicare & have 10 or more employees the provider is required to do what? | To convert to electronic transactions |
| In regards to HIPAA, a provider who sends claims electronically is required to meet what? | HIPAA compliance |
| If a provider has less than 10 employees and submits claims to Medicare on paper can they continue to do so? | Yes if file a waiver |
| Is a provider with less than 10 employees who submits paper claims to Medicare required to be in compliance with HIPAA? | No |
| What are benefits of transaction code sets? | More reliable, timely processing Quicker reimbursement Improved accuracy of data Easier & more efficient access to information Better tracking of transactions Reduction of data entry and office expense |
| medical code sets are considered what? | data elements |
| Taxonomy codes | science of classification; numeric & alpha provider specialty codes |
| What is the most important function of a Practice Management System (PMS)? | Accounts Receivable |
| HIPAA standard apply only to what? | The format in which data is transmitted. |
| What should be done before submitting claims to look for and correct errors? | print an insurance billing worksheet or perform a front end edit |
| Encoder | add on software to PMS that can greatly reduce time it takes to build or review claims before batching |
| Grouper | software designed for use in a network that serves a group of users working on a related project that allows access to the same data |
| What are the 3 sections of the HIPAA security rule? | 1. Administrative safeguards 2. Technical safeguards 3. Physical safeguards |
| Exchange of data in a standardized format through computer systems is technology known as what? | electronic data interchange (EDI) |
| The act of converting computerized data into a code so that unauthorized users are unable to read it is a security system know as what? | encryption |
| Payment to the provider of service of an electronically submitted insurance claim may be received in approximately what timeframe? | two weeks or less |
| Dr. Morgan has 10 or more full-time employees and submits insurance claims for his Medicare patients. Is his medical practice subject to the HIPAA transaction rules? | yes |
| Dr. Montez does not submit insurance claims electronically and has five full-time employees. Is she required to abide by HIPAA transaction rules? | no |
| What is the standard code set for physician services? | CPT |
| What is the standard code set for disease and injuries? | ICD-9-CM Vol 1 & 2 |
| What is the standard code set for pharmaceuticals and biologics? | National drug codes for retail pharmacy transactions |
| the industry standard electronic format for a clinic to submit claims electronically is what? | 837P |
| the industry standard electronic format for hospitals to transmit claims electronically is what? | 837I |
| the industry standard electronic format for insurance carriers to transmit payment to clinics and hospitals is what? | ASC X12N 835 |
| industry standard electronic format to transmit an inquiry is what? | ASC X12N 226 |
| the industry standard electronic format to obtain health benefit and coverage information from an insurance carrier is what? | ASC 12N 270 |
| The signature source code for data element #1351 indicating that there is a signature on file for a Medicare patient is what? | B |
| Name the levels for data collected to construct and submit an electronic claim | 1. High-level information 2. Claim-level information 3. Specialty claim-level information 4. Service line-level information 5. Specialty service line-level information 6. Other information |
| The most important function fo a practice management system is what? | accounts receivable |
| an alert feature that may be incorporated into the software in a physician's office that finds errors so they may be corrected before transmitting a claim is called what? | online error-edit process |
| under HIPAA, data elements that are used uniformly to document why patients are seen (dx) and what is done to them during an encounter (procedure) are known as what? | medical code sets |
| The standard transaction that replaces the paper CMS-1500 claim form and more than 400 versions of the electronic National Standard Format (NSF) is called what? | 837P |
| A paperless computerized system that enables payments automatically to be transferred to a physician's bank account by a 3rd party payer may be done via what? | electronic funds transfer (EFT) |
| an electronic Medicare remittance advice that takes the place of a paper EOB is referred to as what? | ANSI 835 |
| true or false: when transmitting electronic claims, inaccuracies that violate the HIPAA standard transaction format are known as syntax errors. | true |
| true or false: an organization may file a complaint online against someone whose actions impact the ability of a transaction to be accepted or efficiently processed by using the Administrative Simplification Enforcement Tool | true |
| true or false: incidental uses and disclosures of protected health information (PHI) are permissible under HIPAA when reasonable safeguards have been used to prevent inappropriate revelation of PHI | true |
| true or false: deleting files or formatting the hard drive is sufficient to keep electronic protected health information from being accessed. | false |
| true or false: employees who handle sensitive computer documents should sign an annual confidentiality statement. | true |
| true or false: when an insurance billing specialist e-mails a colleague to ask a coding question, it is permissible to refer to the case using the patient's name | false |
Created by:
mpeoples