Issues and Trends in HBI Ch 7

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  • Teaching Notes:
     Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material.
     
  • Learning Outcome: 7.1 Distinguish between the electronic claim transaction and the paper claim form.
    Teaching Notes:
     
    Ask each student to provide the common names for the HIPAA X12 837 Health Care Claim or Equivalent Encounter Information (the “837 claim” or the “HIPAA claim”) and to explain how standardization can reduce errors.
    Discuss the disadvantages of the CMS-1500 paper claim form and the merits of electronic claims transactions.
  • Learning Outcome: 7.1 Distinguish between the electronic claim transaction and the paper claim form.
    Teaching Notes:
     
    Ask students to identify and discuss 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, and they cannot refuse to accept the standard transaction or delay payment of any proper HIPAA transaction, claims included).
     
    Discuss the advantages of the 5010 version electronic claims transactions.
  • Learning Outcome: 7.2 Discuss the content of the patient information section of the CMS-1500 claim.
    Teaching Notes:
     
    Ask students to identify and describe the required information to complete the carrier block (the carrier block allows for a four-line address for the payer).
    Note that in some cases, IN 10D may require a condition code; correct codes can be researched on the NUCC website.
  • Learning Outcome: 7.2 Discuss the content of the patient information section of the CMS-1500 claim.
    Teaching Notes:
     
    Identify and discuss each Item Number (1-13) in the patient information section of the CMS-1500 claim.
     
    Ask students to explain how the information in the patient information section is used in the reimbursement process.
  • Learning Outcome: 7.3 Compare billing provider, pay-to provider, rendering provider, and referring provider.
    Teaching Notes:
     
    Ask students to describe the role of the four different listed types of providers.
  • Learning Outcome: 7.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim.
    Teaching Notes:
     
    Examine and discuss the contents of Table 7.1 with students.
    Ask students to describe how other ID numbers, qualifiers, and reporting outside laboratory services help in the reimbursement process.
    .
  • Learning Outcome: 7.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim.
    Teaching Notes:
     
    Examine and discuss POS codes and their descriptions (found in Table 7.2) with students.
    Ask students to explain how taxonomy codes and administrative code sets improve healthcare reimbursement.
  • Learning Outcome: 7.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim.
    Teaching Notes:
     
    Examine and discuss the Item Numbers in the physician/supplier information section of the CMS-1500 claim.
    Ask students to discuss why accuracy is important here and to provide three strategies of how to ensure accuracy on the job.
  • Learning Outcome: 7.5 Explain the hierarchy of data elements on the HIPAA 837 claim.
    Teaching Notes:
     
    Ask students to give some examples of data elements and explain how they help the reimbursement process.
     
    Discuss with students the differences between a required data element and a situational data element.
  • Learning Outcome: 7.6 Categorize data elements into the five sections of the HIPAA 837P claim transaction.
    Teaching Notes:
     
    Examine the details of the five sections of the HIPAA 837 claim transaction with students (see the five sections listed on this slide).
    Ask students to explain how each section of the HIPAA 837 helps to ensure accurate reimbursement from third-party payers.
  • Learning Outcome: 7.6 Categorize data elements into the five sections of the HIPAA 837P claim transaction.
    Teaching Notes:
     
    Examine and discuss with students the significance of the claim filing indicator and individual relationship codes.
    Ask students to explain how the destination payer and responsible party affect patient and provider.
  • Learning Outcome: 7.6 Categorize data elements into the five sections of the HIPAA 837P claim transaction.
    Teaching Notes:
     
    Examine and discuss with students the significance of the claim control number and line item control numbers.
    Ask students to explain how the claim frequency codes and claim attachment forms affect reimbursement.
  • Learning Outcome: 7.7 Evaluate the importance of checking claims prior to submission, even when using software.
    Teaching Notes:
     
    Ask students to identify and list common errors that can 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.).
    Examine and discuss with students strategies to improve accuracy when completing a claim (double checking, teamwork, software scrubbers, clearinghouse, etc.).
  • Learning Outcome: 7.8 Compare the three major methods of electronic claim transmission.
    Teaching Notes:
     
    Have students debate the value of the direct transmission approach for the transmission of electronic claims.
    Provide examples of the types of errors scrubbers can be expected to catch.
  • Issues and Trends in HBI Ch 7

    1. 1. CHAPTER 7 Healthcare Claim Preparation and Transmission © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
    2. 2. Learning Outcomes 7-2 When you finish this chapter, you will be able to: 7.1 Distinguish between the electronic claim transaction and the paper claim form. 7.2 Discuss the content of the patient information section of the CMS-1500 claim. 7.3 Compare billing provider, pay-to provider, rendering provider, and referring provider. 7.4 Discuss the content of the physician or supplier information section of the CMS-1500 claim. 7.5 Explain the hierarchy of data elements on the HIPAA 837P claim.
    3. 3. Learning Outcomes (continued) When you finish this chapter, you will be able to: 7.6 7.7 7.8 Categorize data elements into the five sections of the HIPAA 837P claim. Evaluate the importance of checking claims prior to submission, even when using software. Compare the three major methods of electronic claim transmission. 7-3
    4. 4. 7-4 Key Terms • • • • • • • • 5010 version 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 • • • • • • CMS-1500 CMS-1500 (08/05) condition code data element destination payer HIPAA X12 837 Health Care Claim: Professional (837P) • HIPAA X12 276/277 Health Care Status Inquiry/Response
    5. 5. 7-5 Key Terms (continued) • individual relationship code • line item control number • National Uniform Claim Committee (NUCC) • other ID number • outside laboratory • pay-to provider • place of service (POS) code • qualifier • • • • • • rendering provider required data element responsible party service line information situational data element taxonomy code
    6. 6. 7.1 Introduction to Healthcare Claims 7-6 • 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 CMS1500, which is a paper claim form
    7. 7. 7.1 Introduction to Healthcare Claims (continued) • National Uniform Claim Committee (NUCC)– organization responsible for claim content – CMS-1500 (08/05)—current paper claim approved by the NUCC  5010 version – new format for the EDI transactions 7-7
    8. 8. 7.2 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 7-8
    9. 9. 7.2 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 7-9
    10. 10. 7.3 Types of Providers 7-10 • It may be necessary to identify four different types of providers: 1. Pay-to provider—person or organization that will be paid for services on a HIPAA claim 2. Rendering provider—term used to identify an alternative physician or professional who provides the procedure on a claim 3. Billing provider—person or organization sending a HIPAA claim 4. Referring provider
    11. 11. 7.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section 7-11 • This part identifies the healthcare 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
    12. 12. 7.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section (continued) • 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 7-12
    13. 13. 7.4 Completing the CMS-1500 Claim: Physician/Supplier Information Section (continued) • 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 7-13
    14. 14. 7.5 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 7-14
    15. 15. 7.6 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 7-15
    16. 16. 7.6 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 7-16
    17. 17. 7.6 Completing the HIPAA 837 Claim (continued) 7-17 • 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 • Claim attachment—additional data in printed or electronic format sent to support a claim – Examples include lab results, specialty consultation notes, and discharge notes
    18. 18. 7.7 Checking Claims Before Transmission 7-18 • Claims are carefully reviewed before transmission • Clean claim—claim 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
    19. 19. 7.8 Clearinghouses and Claim Transmission 7-19 • Practices handle transmission of electronic claims through three major methods: 1. In the direct transmission approach, providers and payers exchange transactions directly 2. The majority of providers use clearinghouses to send and receive data in correct EDI format 3. 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
    20. 20. Summary
    21. 21. Summary
    22. 22. Summary

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