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Survey of Medical Insurance pp ch08
 

Survey of Medical Insurance pp ch08

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 8.1 Distinguish between the electronic claim transaction and the paper claim form. Pages: 276-277 Teaching Notes:   Reinforce the common names for the HIPAA X12 837 Health Care Claim or Equivalent Encounter Information. (The “837 claim” or the “HIPAA claim.”)
  • Learning Outcome: 8.1 Distinguish between the electronic claim transaction and the paper claim form. Pages: 276-277 Teaching Notes:   Have your students list the changes HIPAA has made on the payer side of claim transaction. (Payers may not require providers to make changes or additions to the content of the HIPAA 837 claim. Further, they cannot refuse to accept the standard transaction or delay payment of any proper HIPAA transaction, claims included.)
  • Learning Outcome: 8.2 Discuss the content of the patient information section of the CMS-1500 claim. Pages: 277-285 Teaching Notes:   Ask your students what information is found in the carrier block. (The carrier block allows for a four-line address for the payer.)
  • Learning Outcome: 8.2 Discuss the content of the patient information section of the CMS-1500 claim. Pages: 277-285 Teaching Notes:   Go over the Item Numbers in the patient information section of the CMS-1500 claim.
  • Learning Outcome: 8.3 Compare billing provider, pay-to provider, rendering provider, and referring provider. Page: 285 Teaching Notes:   Quiz your students on the four different types of providers. (As seen on this slide.)
  • Learning Outcome: 8.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim. Pages: 286-299 Teaching Notes:   Examine the contents of Table 8.1 with your students.
  • Learning Outcome: 8.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim. Pages: 286-299 Teaching Notes:   Look at the POS codes and their descriptions (found in Table 8.2) with your students.
  • Learning Outcome: 8.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim. Pages: 286-299 Teaching Notes:   Go over the Item Numbers in the physician/supplier information section of the CMS-1500 claim.
  • Learning Outcome: 8.5 Compare required and situational (required if applicable) data elements on the HIPAA 837 claim. Pages: 299-303 Teaching Notes:   Ask your students to give some examples of data elements.
  • Learning Outcome: 8.6 Identify the five sections of the HIPAA 837 claim transaction and discuss the data elements that complete it. Pages: 303-309 Teaching Notes:   Examine the details of the five sections of the HIPAA 837 claim transaction with your students. (See the five sections on this slide.)
  • Learning Outcome: 8.6 Identify the five sections of the HIPAA 837 claim transaction and discuss the data elements that complete it. Pages: 303-309 Teaching Notes:   Examine the details of the five sections of the HIPAA 837 claim transaction with your students.
  • Learning Outcome: 8.6 Identify the five sections of the HIPAA 837 claim transaction and discuss the data elements that complete it. Pages: 303-309 Teaching Notes:   Examine the details of the five sections of the HIPAA 837 claim transaction with your students.
  • Learning Outcome: 8.7 Explain how claim attachments and credit-debit transactions are handled. Pages: 309-310 Teaching Notes:   Ask your students to explain the reason(s) why they think claim attachments are sometimes necessary.
  • Learning Outcome: 8.8 Define a clean claim. Pages: 310-311 Teaching Notes:   Have your students list some of the common errors that occur when completing a claim. (Missing or incomplete information; missing Medicare or benefits assignment indicator; invalid provider identifier; missing or invalid patient data; missing payer name and or/identifier; incomplete other payer information; invalid procedure codes; etc.)
  • Learning Outcome: 8.9 Identify the three major methods of electronic claim transmission. Pages: 311-313 Teaching Notes:   Ask your students to debate the value of the direct transmission approach for the transmission of electronic claims.

Survey of Medical Insurance pp ch08 Survey of Medical Insurance pp ch08 Presentation Transcript

  • 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