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About Claims

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Definition
Answer
show Auditing  
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A complete record of services provided by a health care professional, along with appropriate insurance information, submitted for reimbursement to a third-party provider.   show
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Agency that converts claims into a standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards.   show
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Basic billing reimbursement steps:   show
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show CMS 1500 Universal Claim Form  
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show Paper Claim/ CMS 1500  
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An insurance claim submitted by computer.   show
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show Electronic Data Interchange (EDI)  
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A group that takes nonstandard medical billing software formats and translates them into the standard Electronic Data Interchange (EDI) formats is called a ________________.   show
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show Dirty Claim  
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A completed insurance claim form submitted, without errors, within the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly.   show
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Authorization by a policyholder that allows a payer to pay benefits directly to provider.   show
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A program set up by a health care provider to ensure compliance with regulations regarding coding and billing to prevent fraud and abuse.   show
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show - Appropriateness of Codes - Payers rules about linkage - Documentation to support codes - Compliance with regulation and guidelines  
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