About Claims
Help!
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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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