Survey of Medical Insurance pp ch08

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Survey of Medical Insurance pp ch08

  1. 1. 8 Health Care Claim Preparation and Transmission
  2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>8.1 Distinguish between the electronic claim transaction and the paper claim form. </li></ul><ul><li>8.2 Discuss the content of the patient information section of the CMS-1500 claim. </li></ul><ul><li>8.3 Compare billing provider, pay-to provider, rendering provider, and referring provider. </li></ul><ul><li>8.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim. </li></ul><ul><li>8.5 Compare required and situational (required if applicable) data elements on the HIPAA 837 claim. </li></ul>8-2
  3. 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>8.6 Identify the five sections of the HIPAA 837 claim transaction and discuss the data elements that complete it. </li></ul><ul><li>8.7 Explain how claim attachments and credit-debit transactions are handled. </li></ul><ul><li>8.8 Define a clean claim. </li></ul><ul><li>8.9 Identify the three major methods of electronic claim transmission. </li></ul>8-3
  4. 4. Key Terms <ul><li>administrative code set </li></ul><ul><li>billing provider </li></ul><ul><li>carrier block </li></ul><ul><li>claim attachment </li></ul><ul><li>claim control number </li></ul><ul><li>claim filing indicator code </li></ul><ul><li>claim frequency code (claim submission reason code) </li></ul><ul><li>claim scrubber </li></ul><ul><li>clean claim </li></ul>8-4 <ul><li>CMS-1500 </li></ul><ul><li>CMS-1500 (08/05) </li></ul><ul><li>condition code </li></ul><ul><li>data element </li></ul><ul><li>destination payer </li></ul><ul><li>HIPAA X12 837 Health Care Claim or Equivalent Encounter Information </li></ul><ul><li>HIPAA X12 276/277 Health Care Status Inquiry/Response </li></ul>
  5. 5. Key Terms (Continued) <ul><li>individual relationship code </li></ul><ul><li>legacy number </li></ul><ul><li>line item control number </li></ul><ul><li>National Uniform Claim Committee (NUCC) </li></ul><ul><li>other ID number </li></ul><ul><li>outside laboratory </li></ul><ul><li>pay-to provider </li></ul><ul><li>place of service (POS) code </li></ul><ul><li>qualifier </li></ul>8-5 <ul><li>rendering provider </li></ul><ul><li>required data element </li></ul><ul><li>responsible party </li></ul><ul><li>service line information </li></ul><ul><li>situational data element </li></ul><ul><li>taxonomy code </li></ul>
  6. 6. 8.1 Introduction to Health Care Claims <ul><li>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 </li></ul><ul><ul><li>The electronic HIPAA claim is based on the CMS-1500 , which is a paper claim form </li></ul></ul>8-6
  7. 7. 8.1 Introduction to Health Care Claims (Continued) <ul><li>National Uniform Claim Committee (NUCC)– organization responsible for claim content </li></ul><ul><ul><li>CMS-1500 (08/05)— current paper claim approved by the NUCC </li></ul></ul><ul><li>Legacy number— provider’s identification number issued prior to the National Provider Identification system </li></ul>8-7
  8. 8. 8.2 Completing the CMS-1500 Claim: Patient Information Section <ul><li>The CMS-1500 claim has a carrier block and thirty-three Item Numbers (INs) </li></ul><ul><li>Carrier block— data entry area in the upper right of the CMS-1500 </li></ul><ul><li>Condition code— two-digit numeric or alphanumeric codes used to report a special condition or unique circumstance </li></ul>8-8
  9. 9. 8.2 Completing the CMS-1500 Claim: Patient Information Section (Continued) <ul><li>The upper portion of the CMS-1500 claim form (Item Numbers 1-13): </li></ul><ul><ul><li>Lists demographic information about the patient and specific information about the patient’s insurance coverage </li></ul></ul><ul><ul><li>Information is entered based on the patient information form, insurance card, and payer verification data </li></ul></ul>8-9
  10. 10. 8.3 Types of Providers <ul><li>It may be necessary to identify four different types of provider: </li></ul><ul><ul><li>Pay-to provider— person or organization that will be paid for services on a HIPAA claim </li></ul></ul><ul><ul><li>Rendering provider— term used to identify an alternative physician or professional who provides the procedure on a claim </li></ul></ul><ul><ul><li>Billing provider— person or organization sending a HIPAA claim </li></ul></ul><ul><ul><li>Referring provider </li></ul></ul>8-10
  11. 11. 8.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section <ul><li>This part identifies the health care provider, describes the services performed, and gives the payer additional information to process the claim </li></ul><ul><li>Other ID number— additional provider identification number </li></ul><ul><li>Qualifier— two-digit code for a type of provider identification number other than the NPI </li></ul><ul><li>Outside laboratory— purchased laboratory services </li></ul>8-11
  12. 12. 8.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section (Cont.) <ul><li>Service line information— information about services being reported </li></ul><ul><li>Place of service (POS) code— administrative code indicating where medical services were provided </li></ul><ul><li>Taxonomy code— administrative code set used to report a physician’s specialty </li></ul><ul><li>Administrative code set— required codes for various data elements </li></ul>8-12
  13. 13. 8.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section (Cont.) <ul><li>The lower portion of the CMS-1500 claim form (Item Numbers 14-33): </li></ul><ul><ul><li>Contains information about the provider or supplier and the patient’s condition, including the diagnoses, procedures, and charges </li></ul></ul><ul><ul><li>Information is entered based on the encounter form </li></ul></ul>8-13
  14. 14. 8.5 The HIPAA 837 Claim <ul><li>Data element— smallest unit of information in a HIPAA transaction </li></ul><ul><ul><li>Example: a patient’s name </li></ul></ul><ul><ul><li>Required data element— information that must be supplied on an electronic claim </li></ul></ul><ul><ul><li>Situational data element— information that must be on a claim in conjunction with certain other data elements </li></ul></ul>8-14
  15. 15. 8.6 Completing the HIPAA 837 Claim <ul><li>The five sections of the HIPAA 837 claim transaction include: </li></ul><ul><ul><li>Provider information </li></ul></ul><ul><ul><li>Subscriber information </li></ul></ul><ul><ul><li>Payer information </li></ul></ul><ul><ul><li>Claim information </li></ul></ul><ul><ul><li>Service line information </li></ul></ul>8-15
  16. 16. 8.6 Completing the HIPAA 837 Claim (Continued) <ul><li>Responsible party— other person or entity who will pay a patient’s charges </li></ul><ul><li>Claim filing indicator code— administrative code that identifies the type of health plan </li></ul><ul><li>Individual relationship code— administrative code specifying the patient’s relationship to the subscriber </li></ul><ul><li>Destination payer— health plan receiving a HIPAA claim </li></ul>8-16
  17. 17. 8.6 Completing the HIPAA 837 Claim (Continued) <ul><li>Claim control number— unique number assigned to a claim by the sender </li></ul><ul><li>Claim frequency code (or claim submission reason code ) — administrative code that identifies the claim as original, replacement, or void/cancel action </li></ul><ul><li>Line item control number— unique number assigned to each service line item reported </li></ul>8-17
  18. 18. 8.7 Handling Claim Attachments and Credit-Debit Transactions <ul><li>Claim attachment— additional data in printed or electronic format sent to support a claim </li></ul><ul><ul><li>Examples include lab results, specialty consultation notes, and discharge notes </li></ul></ul><ul><li>Patient credit-debit transactions are carefully processed and recorded by the practice </li></ul><ul><ul><li>The amount charged is reported to the patient once billed </li></ul></ul>8-18
  19. 19. 8.8 Checking Claims Before Transmission <ul><li>Claims are carefully reviewed before transmission </li></ul><ul><li>Clean claim—c laim accepted by a health plan for adjudication </li></ul><ul><ul><li>Properly completed and contains all the necessary information </li></ul></ul><ul><li>HIPAA X12 276/277 Health Care Claim Status Inquiry/Response— electronic format used to ask payers about claims </li></ul>8-19
  20. 20. 8.9 Clearinghouses and Claim Transmission <ul><li>Practices handle the transmission of electronic claims with three major methods: </li></ul><ul><ul><li>In the direct transmission approach, providers and payers exchange transactions directly </li></ul></ul><ul><ul><li>The majority of providers use clearinghouses to send and receive data in correct EDI format </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><li>Claim scrubber— software that checks claims to permit error correction </li></ul>8-20

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