Chapter 8 The Electronic Claim

electronic funds transfer (EFT)

a paperless computerized system that enables frunds to be debited, credited, or transferred and eliminates the need for personal handling of checks

code set

any set of codes with their descriptions used to encode data elements, such as table of terms, medical concepts, medical diagnostic codes, or medical procedure codes

audit trail

electronic transactions build an audit trail; a chronologic record of submitted data that can be traced to the source to determine the place or origin

trading partners

entities that function alternatively as sender and receiver

Scrubber report

indicates the total number of claims, charges, and dollar amounts that were received by the clearinghouse and scrubbed for claims submitted to Massachusetts Insurance Plan

OSCAR

online survey certification and reporting system

medical code sets

data elements used uniformly to document why patients are seen (that is, diagnosis, ICS_10-CM) and what is done to them during their encounter (that is, procedure, CPT-4, and HCPCS)

administrative safeguards

prevent unauthorized use or disclosure through administrative actions; passwords, internal audits, risk analysis, termination procedures

technical safeguards

technologic controls in place to protect and control access to information on computers in the health care organization and include the following; access controls for each staff member, audit controls keep track of logins and activity, and automatic log offs

Electronic Data Interchange (EDI)

the exchange of data through computer systems (for example, health insurance claims are exchanged between health care providers and insurance carriers); data is sent back and forth in a standardized format via computer linkages between entities

Under the ACA

the federal government has established a uniform procedure for electronically transferring funds as part of HIPAA Title II Adminstrative Simplification

TCS - transaction and code sets rule

the intent of TCS requirements is to achieve a single standard

PMS Practice Management System

the most important function of a PMS is accounts receivable; HIPAA does not apply to the format of stored data within the PMS database

encryption

used to assign a secret code to represent data

What does a clearinghouse do?

1. claims are checked electronically (scrubbed) 2. claims that are rejected during the editing process are sent back to the health care provider electronically along with a report hat lists the needed corrections 3. batches of claims that pass all edits are then sent to each separate insurance payer; several claims can be submitted to various insurance payers in a single batch electronic transmission

Disadvantages of carrier direct submission are:

1. cost of purchasing/leasing equipment & software 2. hiring/training staff to process claims 3. establishing claims processing agreements with each insurance carrier.

Methods of sending claims

1. data transmission via cable modem, digital subscriber line DSL 2. data directly keyed into payer system DDE (direct data entry) 3. PMS - an in-house shared system or application service provider (ASP); renting internet space

Advantages of carrier direct submission are:

1. provider retains control over claims submissions 2. patient medical records are readily available if needed 3. the billing specialist can readily respond to error-edit messages

a HIPAA-ready PMS may allow the following:

1. setting security access to patient files in the software 2. indicating date of receipt and signature of NPP (Notice of Privacy Practices) 3. Inserting date of patient's authorization 4. Maintaining files of practice's authorization and notification forms 5. tracking requests for amendments, requests for restrictions on use and disclosure of protected health information (PHI), and indications of whether the physician agreed to or denied the request tracking expiration dates

advantanges of clearinghouses

1. translation of various formats to the HIPAA compliant standard format 2. reduction in time of claims preparation 3. cost-effective method through loss prevention 4. fewer claim rejections 5. fewer delays in processing and quicker response time 6. more accurate coding with claims edits 7. consistent reimbursement

EDI 837

An 837 file is an electronic file that contains patient claim information. This file is submitted to an insurance company or to a clearinghouse instead of printing and mailing a paper claim. • The data in an 837 file is called a Transaction Set.

CDT

Current Dental Terminology

NDC

National Drug Code

CPT

Current Procedural Terminology

code sets

Any set of codes with their descriptions used to encode data elements such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.

common attachments

CMNs are Certificates of Medical Necessity, discharge summaries, and operative reports

modifier -22

Don't bill codes using modifier -22 electronically unless the carrier receives documents (called attachments) to justify more payment

EOMB

Explanation of Medicare Benefits

EIN - Employer identification number

HIPAA requires that the EIN be used to identify employers rather than inputting the name of the company when submitting claims

837P

HIPAA-mandated electronic transaction for professional claims.

HCPCS

Healthcare Common Procedure Coding System

A clean claim is one that contains all required data elements needed to process and pay the claim.

Methods used to ensure clean electronic claims: 1. incorporate claim scrubber software (prebill/edit processing) to identify errors and correct them on initial submission 2. verify, file, and keep all transmission reports 3. track clearinghouse claims to ensure successful transmission 4. ensure that your computer software is consistent with the claims rules 5. verify that your software correctly prints the CMS-1500 form 6. use encoder software 7. use an electronic clearinghouse 8. perform single and batch claims review

taxonomy codes

Numeric and alpha provider specialty codes that are assigned and classify each health care provider when transmitting electronic insurance claims; self selected by the provider and based on education and training, and used to define specialty (for example, nurse practitioner, family practice

POS

Point of Service

PMS

Practice Management System

encoder

Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system

EDI 835

The EDI 835 transaction set is called Health Care Claim Payment and Remittance Advice. ... The 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both.

ICD-10-CM Official Guidelines for Coding and Reporting

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification)

covered entity

an entity that transmits health information in electronic form in connection with a transaction covered by HIPAA

National Standard Format (NSF)

The most widely accepted format for transmitting CMS forms electronically.

electronic medical claims (EMCs)

The system called electronic medical claims is used for nearly all Medicare transactions, including claims submission payment, direct deposit, online eligibility verification, etc.; claims can be submitted to CMS MACs via direct data entry screens

zero balance account (ZBA)

a deposit-only bank account provides protection against cyber-thieves; this account has blocks and filters so that it accepts only deposits

batch

a group of claims for different patients sent at the same time from one facility

real time

allows for instant information

encounter form

also called the superbill; it is a listing of the diagnosis, procedures, and charges for a pt's visit (also known as a charge slip, multipurpose billing form, patient service slip, routing form, or transaction slip)

physical safeguards

also prevent unauthorized access to PHI; prevent electronic information systems from natural and environment hazards and unauthorized intrusion; media and equipment controls, physical access controls limit unauthorized access to certain areas, secure workstations

ASET Administrative Simplification Enforcement Tool

an electronic tool to assist health care providers, payers, clearinghouses, and others to submit complaints; this tool enables individuals or organizations to file a complaint online against and entity "whose actions impact the ability of a transaction to be accepted and/or efficiently processed:

clearinghouse

an entity that receives the electronic transmission of claims (EDI) from the health care provider's office and translates it to a standard format prescribed in HIPAA regulations

batched claims

can be divided according to insurance type or date(s) of service and are ideally sent during low-volume times

interactive transactions

involve back and forth communication between two computer systems - online real time

Batch Claim Report Billed Summary

lists each patient's name, total charges for medical services, batch number, billing number, name of insurance company billed, and chronologic date on which the claim was transmitted

clearinghouses

may charge a flat fee per claim or a monthly fee; a vendor agreement of sorts will be in place = contracts may be a business associate agreement, a trading partner agreement or another contract

NSF

non-sufficient funds

electronic remittance advice ERA

notice of payments and adjustments sent to providers, billers, and suppliers; After a claim has been received and processed, the insurance carrier produces the ERA, which may serve as a companion to a claim payment or as an explanation when there is no payment (EOB); it explains reimbursement decisions

taxonomy codes

taxonomy codes are maintained by the NUCC (National Uniform Claim Committee)

advantages of electronic claim submission

require no signature or stamp, no search for a third-party payer's address, no postage fees or trips to the post office, and no storage of claim forms in a file cabinet; cash flow is improved and less time is spent processing claims, thereby freeing staff for other duties; the audit trail offers proof of receipt; online error edit process that may be incorporated in the software

Send and Receive File Reports

shows that a file is received by the clearinghouse and/or payer and also notifies the billing specialist when a file has been sent to the provider's account for review

claim attachments

supplemental documents that provide additional medical information to the claims processor that cannot be included within the electronic claim format

HIPAA standard transactions

the specific electronic file formats in which medical data are compiles to be used throughout the health care industry

HIPPA Transaction and Code Sets rule (TCS)

this regulation defines the standardized methods for transmitting electronic health information. The TCS process includes any set of HIPAA-approved codes with their descriptions used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. TCS regulations were implemented to streamline electronic data interchange

required data elements

when constructing a claim, the supporting code sets are made up of "required" and "situational" data elements; data elements that must be used to be in compliance with a HIPAA standard transaction

situational data elements

when constructing a claim, the supporting code sets are made up of "required" and "situational" data elements; situational means that the item depends on the data content or context

carrier direct system

with this system, the data are transmitted electronically directly to the payer's system - eliminates the need for a clearinghouse