Survey of Medical Insurance pp ch08

8 Health Care Claim Preparation and Transmission

Learning Outcomes
When you finish this chapter, you will be able to:
8.1 Distinguish between the electronic claim transaction and the paper claim form.
8.2 Discuss the content of the patient information section of the CMS-1500 claim.
8.3 Compare billing provider, pay-to provider, rendering provider, and referring provider.
8.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim.
8.5 Compare required and situational (required if applicable) data elements on the HIPAA 837 claim.
8-2

Learning Outcomes (Continued)
When you finish this chapter, you will be able to:
8.6 Identify the five sections of the HIPAA 837 claim transaction and discuss the data elements that complete it.
8.7 Explain how claim attachments and credit-debit transactions are handled.
8.8 Define a clean claim.
8.9 Identify the three major methods of electronic claim transmission.
8-3

Key Terms
administrative code set
billing provider
carrier block
claim attachment
claim control number
claim filing indicator code
claim frequency code (claim submission reason code)
claim scrubber
clean claim
8-4
CMS-1500
CMS-1500 (08/05)
condition code
data element
destination payer
HIPAA X12 837 Health Care Claim or Equivalent Encounter Information
HIPAA X12 276/277 Health Care Status Inquiry/Response

Key Terms (Continued)
individual relationship code
legacy number
line item control number
National Uniform Claim Committee (NUCC)
other ID number
outside laboratory
pay-to provider
place of service (POS) code
qualifier
8-5
rendering provider
required data element
responsible party
service line information
situational data element
taxonomy code

8.1 Introduction to Health Care Claims
The HIPAA-mandated electronic transaction for claims is the HIPAA X12 837 Health Care Claim or Equivalent Encounter Information— used to send a claim to primary and secondary payers
The electronic HIPAA claim is based on the CMS-1500 , which is a paper claim form
8-6

8.1 Introduction to Health Care Claims (Continued)
National Uniform Claim Committee (NUCC)– organization responsible for claim content
CMS-1500 (08/05)— current paper claim approved by the NUCC
Legacy number— provider’s identification number issued prior to the National Provider Identification system
8-7

8.2 Completing the CMS-1500 Claim: Patient Information Section
The CMS-1500 claim has a carrier block and thirty-three Item Numbers (INs)
Carrier block— data entry area in the upper right of the CMS-1500
Condition code— two-digit numeric or alphanumeric codes used to report a special condition or unique circumstance
8-8

8.2 Completing the CMS-1500 Claim: Patient Information Section (Continued)
The upper portion of the CMS-1500 claim form (Item Numbers 1-13):
Lists demographic information about the patient and specific information about the patient’s insurance coverage
Information is entered based on the patient information form, insurance card, and payer verification data
8-9

8.3 Types of Providers
It may be necessary to identify four different types of provider:
Pay-to provider— person or organization that will be paid for services on a HIPAA claim
Rendering provider— term used to identify an alternative physician or professional who provides the procedure on a claim
Billing provider— person or organization sending a HIPAA claim
Referring provider
8-10

8.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section
This part identifies the health care provider, describes the services performed, and gives the payer additional information to process the claim
Other ID number— additional provider identification number
Qualifier— two-digit code for a type of provider identification number other than the NPI
Outside laboratory— purchased laboratory services
8-11

8.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section (Cont.)
Service line information— information about services being reported
Place of service (POS) code— administrative code indicating where medical services were provided
Taxonomy code— administrative code set used to report a physician’s specialty
Administrative code set— required codes for various data elements
8-12

8.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section (Cont.)
The lower portion of the CMS-1500 claim form (Item Numbers 14-33):
Contains information about the provider or supplier and the patient’s condition, including the diagnoses, procedures, and charges
Information is entered based on the encounter form
8-13

8.5 The HIPAA 837 Claim
Data element— smallest unit of information in a HIPAA transaction
Example: a patient’s name
Required data element— information that must be supplied on an electronic claim
Situational data element— information that must be on a claim in conjunction with certain other data elements
8-14

8.6 Completing the HIPAA 837 Claim
The five sections of the HIPAA 837 claim transaction include:
Provider information
Subscriber information
Payer information
Claim information
Service line information
8-15

8.6 Completing the HIPAA 837 Claim (Continued)
Responsible party— other person or entity who will pay a patient’s charges
Claim filing indicator code— administrative code that identifies the type of health plan
Individual relationship code— administrative code specifying the patient’s relationship to the subscriber
Destination payer— health plan receiving a HIPAA claim
8-16

8.6 Completing the HIPAA 837 Claim (Continued)
Claim control number— unique number assigned to a claim by the sender
Claim frequency code (or claim submission reason code ) — administrative code that identifies the claim as original, replacement, or void/cancel action
Line item control number— unique number assigned to each service line item reported
8-17

8.7 Handling Claim Attachments and Credit-Debit Transactions
Claim attachment— additional data in printed or electronic format sent to support a claim
Examples include lab results, specialty consultation notes, and discharge notes
Patient credit-debit transactions are carefully processed and recorded by the practice
The amount charged is reported to the patient once billed
8-18

8.8 Checking Claims Before Transmission
Claims are carefully reviewed before transmission
Clean claim—c laim accepted by a health plan for adjudication
Properly completed and contains all the necessary information
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response— electronic format used to ask payers about claims
8-19

8.9 Clearinghouses and Claim Transmission
Practices handle the transmission of electronic claims with three major methods:
In the direct transmission approach, providers and payers exchange transactions directly
The majority of providers use clearinghouses to send and receive data in correct EDI format
Some payers offer online direct data entry (DDE) to providers, which involves using an Internet-based service into which employees key the standard data elements
Claim scrubber— software that checks claims to permit error correction
8-20

Survey of Medical Insurance pp ch08

by Fallon Brewington on Jan 04, 2012

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Survey of Medical Insurance pp ch08 Presentation Transcript