Medical Billing Chapter 17 Flashcards

Third Party Reimbursement

• Refers to payment for services provided by a third party, not the patient.

History of Claims

• Providers encouraged to submit claims electronically since 2005.
• Compliance with HIPAA is essential for reimbursement processes.

CMS 1500 Form

• Standard claim form used in medical offices.
• Accepted by Medicare, Medicaid, and most health insurance groups for reimbursement.

Common Claim Errors

• Errors detected by third-party payers can lead to claim rejection.
• Medical facilities must resubmit corrected claims upon rejection.

National Provider Identifier (NPI)

• Unique identification for healthcare providers in a 10-digit format.

Procedure to Complete a Claim Form

• Ensure a photocopy of the patient's insurance card is available before submission.

Medicare Signature Acceptance

• Medicare accepts stamped signatures; other carriers accept typed names and credentials as valid signatures.

Filing Claims Electronically

• Reduces turnaround time and preparation time for claims processors.
• Enhances efficiency in the claims filing process.

CMS 1450 Form

• Also known as the UB-40 form, used for institutional claims.

Clearinghouses

• Facilitate claims processing for providers, charging fees such as startup, monthly, or per-claim transaction fees based on volume.

Electronic Claims Tracking

• Claims typically reach payers within 24 hours, accelerating payment processes.
• Online tracking allows real-time updates and alerts for claim issues.

Manual Claims Tracking

• Involves a lengthy process that can lead to payment delays.

Delinquent Claims

• Claims not paid within designated periods require follow-up if no denial is received.

Remittance Medicare

• A multipurpose form necessary with payments sent to the Federal Communications Commission.

Procedure Payments and Adjustments to Patient Accounts

• Insurance adjustments must be recorded in the credit column of patient accounts.

Procedure Steps

• Document the name of the insurance company, payment date, and adjustment details for records.