Questions and Answers
What does adjudication refer to?
What is aging in accounts receivable?
Classification of accounts receivable by length of time.
What are claim status category codes used for?
To report the status group for a claim.
What is the purpose of claim status codes?
Signup and view all the answers
Define claim turnaround time.
Signup and view all the answers
What is the CMS-1500 (08/05) claim form?
Signup and view all the answers
What is a companion guide?
Signup and view all the answers
What is a crossover claim?
Signup and view all the answers
What are data elements in a HIPAA transaction?
Signup and view all the answers
What does determination refer to in claims processing?
Signup and view all the answers
What is the process of gathering information to adjudicate a claim called?
Signup and view all the answers
What is a filter in data processing?
Signup and view all the answers
Define HIPAA X12 837 Health Care Claim.
Signup and view all the answers
Define HIPAA X12 276/277 Health Care Claim Status Inquiry/Response.
Signup and view all the answers
What is an insurance aging report?
Signup and view all the answers
What is a medical necessity denial?
Signup and view all the answers
What does NUCC stand for?
Signup and view all the answers
What are navigator buttons?
Signup and view all the answers
What is the pending claim status?
Signup and view all the answers
What are prompt payment laws?
Signup and view all the answers
What is the suspended claim status?
Signup and view all the answers
Define timely filing in claims processing.
Signup and view all the answers
Under the Patient Protection and Affordable Care Act (PPACA), the timely filing requirements for Medicare claims is ____ calendar year after the date of service.
Signup and view all the answers
The CMS-1500 claim has 33 numbered boxes representing about ____ data elements.
Signup and view all the answers
The HIPAA 837 has a maximum of 244 segments representing about ______ elements.
Signup and view all the answers
The HIPAA 837 uses the term _____ for the insurance policyholder or guarantor.
Signup and view all the answers
The CMS-1500 uses the term _____ for the insurance policyholder or guarantor.
Signup and view all the answers
The HIPAA claim requires a _______, which is an administrative code that identifies the type of health plan.
Signup and view all the answers
Match the following components of the 837 form with their descriptions:
Signup and view all the answers
What does HIPAA 837P refer to?
Signup and view all the answers
What does HIPAA 837I refer to?
Signup and view all the answers
What does HIPAA 837D refer to?
Signup and view all the answers
What is the Direct to Payer approach?
Signup and view all the answers
In the 'Direct to Payer' approach, the _______ must supply all the HIPAA data elements.
Signup and view all the answers
Define Direct Data Entry (DDE).
Signup and view all the answers
What is a clearinghouse in claims processing?
Signup and view all the answers
Match the following payers for patients covered by Medicare and Medicaid:
Signup and view all the answers
What is a 997 Functional Acknowledgment?
Signup and view all the answers
What does an A code in HIPAA 277 Claim Status Code signify?
Signup and view all the answers
What does a P code in HIPAA 277 Claim Status Code indicate?
Signup and view all the answers
What does an F code in HIPAA 277 Claim Status Code signify?
Signup and view all the answers
What does an R code in HIPAA 277 Claim Status Code indicate?
Signup and view all the answers
What does an E code in HIPAA 277 Claim Status Code indicate?
Signup and view all the answers
What are the five steps health plans follow to adjudicate claims?
Signup and view all the answers
What is remittance advice?
Signup and view all the answers
What is electronic remittance advice (ERA)?
Signup and view all the answers
What does X12 835 Electronic Remittance Advice pertain to?
Signup and view all the answers
What is a claim control number?
Signup and view all the answers
What is autoposting in claims management?
Signup and view all the answers
What are claim adjustment group codes (CAGCs)?
Signup and view all the answers
What are claim adjustment reason codes (CARCs)?
Signup and view all the answers
What is a remittance advice remark code (RARC)?
Signup and view all the answers
What does PR stand for in CAGC?
Signup and view all the answers
What does CO stand for in CAGC?
Signup and view all the answers
What does CR stand for in CAGC?
Signup and view all the answers
What does OA stand for in CAGC?
Signup and view all the answers
What does PI stand for in CAGC?
Signup and view all the answers
Define electronic funds transfer (EFT).
Signup and view all the answers
What are capitation payments?
Signup and view all the answers
What is an appeal in claims processing?
Signup and view all the answers
Who is a claimant?
Signup and view all the answers
Who is an appellant?
Signup and view all the answers
What are the three levels in pursuing an appeal?
Signup and view all the answers
What authority does the state insurance commission have?
Signup and view all the answers
What are postpayment audits?
Signup and view all the answers
What is a Recovery Audit Contractor (RAC)?
Signup and view all the answers
Offices should respond to all RAC inquiries within ____ days.
Signup and view all the answers
What is an overpayment?
Signup and view all the answers
What is a takeback?
Signup and view all the answers
What is a patient statement?
Signup and view all the answers
What is an explanation of benefits (EOB)?
Signup and view all the answers
What are standard statements?
Signup and view all the answers
What are remainder statements?
Signup and view all the answers
What is a patient day sheet?
Signup and view all the answers
What is a procedure day sheet?
Signup and view all the answers
What is a payment day sheet?
Signup and view all the answers
What is an aging report?
Signup and view all the answers
What is a patient aging report?
Signup and view all the answers
What is PQRI (Physician Quality Reporting Initiative)?
Signup and view all the answers
What are performance measures?
Signup and view all the answers
Under HIPAA, covered entities must keep records of HIPAA compliance for _____ years.
Signup and view all the answers
What does the HIPAA Security Rule require?
Signup and view all the answers
What is a patient ledger?
Signup and view all the answers
The average patient is now responsible for paying nearly ___ % of medical bills.
Signup and view all the answers
What is a tickler in billing?
Signup and view all the answers
What is the Fair Debt Collection Practices Act?
Signup and view all the answers
What does the Truth in Lending Act regulate?
Signup and view all the answers
What is the Equal Credit Opportunity Act?
Signup and view all the answers
What is a payment plan?
Signup and view all the answers
What is an uncollectible account?
Signup and view all the answers
What is a means test?
Signup and view all the answers
What is a write-off?
Signup and view all the answers
What does bankruptcy mean?
Signup and view all the answers
What is a small-balance account?
Signup and view all the answers
Study Notes
Claim Adjudication and Processing
- Adjudication: Determines payment eligibility for a claim.
- Claim Turnaround Time: Mandated time frame for health plans to process a claim.
- Claim Status Codes: Provide answers to inquiries about claims.
- Pending Status: Indicates the claim is under review for additional information.
- Suspended Status: Claim is developing; further action is pending.
Claims and Formats
- CMS-1500 Form: Standard paper claim form mandated for insurance submissions.
- HIPAA X12 837: Electronic claim format for health care claims.
- Direct Data Entry (DDE): Manual claims entry on a payer's website.
- Companion Guide: Payer's reference for claim edits and formatting standards.
- Claim Filing Indicator Code: Identifies type of health plan on claims.
Claims Management and Tracking
- Insurance Aging Report: Outlines responses by payers to claims over time.
- Claim Control Number: Unique identifier assigned to claims for tracking and matching payments.
- Electronic Remittance Advice (ERA): Lists details of payments and denials for claims.
Financial Reconciliation
- Remittance Advice: Document explaining payment outcomes for claims.
- Claim Adjustment Reason Codes (CARCs): Explain mismatches in billed and paid amounts.
- Claim Adjustment Group Codes (CAGCs): Detail general types of adjustments made to claims.
- Overpayment: Excessive payment received by providers requiring reconciliation.
Appeals and Legal Framework
- Appeal Process: Challenge decisions made by payers regarding claims.
- State Insurance Commission: Oversees reviews of denied claims and appeals.
- Fair Debt Collection Practices Act: Regulates debt collection practices and protects consumers.
Patient Accounts and Financial Responsibility
- Patient Ledger: Accounts detailing charges, payments, and adjustments for each patient.
- Uncollectible Account: Patients’ debts that cannot be collected and written off.
- Payment Plan: Agreement allowing patients to settle dues in installments.
Important Laws and Guidelines
- HIPAA Security Rule: Protects electronic patient health information (ePHI).
- Truth in Lending Act: Regulates financial charges and late payment fees.
- Equal Credit Opportunity Act: Prohibits discrimination in credit access based on demographic factors.
Summary Reports
- Patient Day Sheet: Summarizes daily patient activity.
- Procedure Day Sheet: Lists all procedures performed in a day.
- Payment Day Sheet: Organizes daily payments received by provider.
Compliance and Timing
- Timely Filing: Specifies days post-service for claims submissions.
- Postpayment Audits: Retrospective reviews to ensure accuracy and necessity of services.
- Required Record Keeping: HIPAA mandates record retention for six years.
Performance and Quality Reporting
- PQRI: Incentivizes physicians for reporting on quality measures related to treatment plans.
- Performance Measures: Evaluate healthcare processes and outcomes, focusing on quality aims.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Prepare for your MED134 final exam with these flashcards covering key terms and definitions. Enhance your understanding of adjudication, aging, claim status codes, and more. Ideal for students to test their knowledge effectively.