Ch. 8; Electronic Data Interchange: Transactions and Security
Payment to the provider of service of an electronically submitted insurance claim may be received in approximately
2 weeks or less
The standard transaction that replaces the paper CMS-1500 ()*-05) claim form and more than 400 versions of the electronic National Standards Format is called the
837P
An electronic Medicare remittance advice that takes the place of a paper Medicare explanation on benefits (EOB) is referred to as :
ANSI 820
The most important function of a practice management system is
Accounts receivable
Code sets
Allowable sets of codes that anyone could use to enter into a specific space on a form.
Accredited Standards Committee X12 (ASC X12)
American National Standards Institute formed this which developed the US standards body for the cross industry development, maintenance, and publication of ED exchange standards
Weekly Guidelines and Protocols
Batch, scrub, edit, and transmit claims Analyze previous weeks rejected and resubmitted claims Note any problematic claims and resolve outstanding files Research unpaid claims Make follow up calls to resolve reasons for rejections, such as incorrect NPI, incorrect data, incomplete data or wrong format
Methods to ensure clean claims
Claim scrubber software Encoder software Electronic Clearinghouse Single and batch claim review
Standard Unique Identifiers
EIN NPI HPI UPI
Exchange of data in a standardized format through computer systems is a technology known as
Electronic data into a code interchange (EDI)
Standard Code Sets include
ICD-9-CM CPT-4 CDT (Code on Dental Procedures and Nomenclature) NDC ICD-10-CM
Under HIPAA, data element that are used uniformly to document why patients are seen (diagnosis) and what is done to them during their encounter (procedure) are known as
Medical code sets
Data elements
Medical codes sets used uniformly to document why patients are seen.
MTS
Medicare Transaction System Part A (hospital services) Part B (Outpatient medical services)
Benefits of TCS and EDI
More reliable and timely processing Improved accuracy of data Easier and more efficient access to information Reduction of data entry Reduction in office expenses
Dr. Maria Montez does not submit insurance claims electronically and has five full- time employees. IS she required to aid by HIPPA transaction rule?
NO
An alert feature that may be incorporated into the software in a physician's office that finds errors so they may be corrected before transmitting an insurance claim is called a/ an
Online error-edit process
Daily Guidelines and Protocols
Post charges in practice Management system Post payments in PMS Batch, scrub, edit, and transmit claims; retrieve transmission reports Review Clearinghouse/payer transmission reports Audit claims batched and transmitted with confirmation reports Correct rejections and resubmit claims
Interactive transactions include
Real time EFT
End of Month Guidelines and Protocols
Run month end aging reports Review all claim rejection reports, making sure all problems are resolved and claims resubmitted Update PMS with payer info, such as EIN and NPI Run patient statements in office or through clearinghouse
Taxonomy
Science of Classification; include general practice, family practice, nurse practitioner. These are necessary because some institutional providers may not choose to apply for an NPI
Other data elements required under HIPAA TCS
Taxonomy codes Patient Account number Relationship to patient Facility code value Patient signature source code
Accounts recievable
The most important function of a practice management system
Advantages of a Clearinghouse
Translation of formats to HIPAA compliant format Reduction in time of claims processing Cost effective through loss prevention Fewer claims rejections Fewer delays in processing More accurate coding with claims edits Consistent reimbursement
Dr. Morgan has 10 or more full-time employees and submits insurance claims for his Medicare patients. Is his medical practice subject to the HIPAA transaction rules ?
YES
audit trail
a chronologic record of submitted data that can be traced to the source to determine the place of origin.
batch
a group of claims for different patients sent at the same time from one facility.
Paper and electronic claims begin
before, during, and after service is rendered..
Encounter form
document used to record information about the service rendered to a patient.
Standard Transactions
electronic files in which medical data are compiled to produce a specific format to be used throughout the health care industry
A paperless computerized system that enables payments automatically to be transferred to a physician's bank account by third -party may be done via
electronic funds transfer (EFT)
Administration Simplification Enforcement Tool ASET
enables individuals or organizations to file a complaint online against an entity "whose actions impact the ability of a transaction to be accepted and or efficiently processed".
Add on software to a practice management system that can reduced the time it takes to build or review a claim before batching is known as a / an
encoder
supporting codes sets
encompass both medical and nonmedical data
The act of converting computerized data into a code so that unauthorized users are unable to read it is a security system known
encryption
Practice Management System (PMS)
goal is the ability to prepare, send, receive, and process HIPAA standard electronic transactions.
Software that is used in a network that serves a group of users working on a related project allowing access to the same data is a /an
grouper
Reasonable Safeguards
measurable solutions based on accepted standards that are implemented and periodically monitored to demonstrate that the office is in compliance.
carrier direct
medical practices link directly to the insurance carrier without the use of a clearinghouse
To look for correct all errors before the health claim is transmitted to the insurance carrier, you may
print an insurance billing worksheet or perform a front-end edit (online error checking)
Clearinghouse
receives the electronic transmission of claims from the health care provider and translates it into a standard format prescribed in HIPAA regulations.
Clearinghouse duties
separating the claims by carrier performing software edits on each claim to check for errors transmitting claims electronically to correct the insurance payer
grouper
software designed for use in a network that serves a group of users working on a related project that allows access to the same data.
audit tool
the encoder can be helpful in performance improvement by identifying problem areas in the billing process
electronic medical claims (EMC)
used for nearly all Medicare transactions, including claims submission, payment, direct deposit, online eligibility verification, coordination of benefits, and claims status.
Name the standard code sets used for the following :
a.physician service: CPT-4 b. disease and injuries : ICD-9-CM c. pharmaceuticals and biologics : NDC national Drug Codes
HIPAA Transaction and Code Set Rule (TCS)
achieve a higher quality of care reduce administrative costs by streamlining the processing of routine administrative and financial transactions
encoder
add on software to PMS that can greatly reduce the time it takes to build or review a claim before batching.
Online error edit process
alerts the person processing the claim to any errors immediately so that the correction can be made before transmission of the claim.
Carrier direct system
Fiscal agents for medicare, Medicaid, TRICARE, and private third party payers use this system
Name the levels for data collected to construct and submit an electronic claim
a. High - level information b. Claim-level information c. Specialty claim-level information d. Service line-level information e. Specialty service line-level information f. Other information
List benefits of using HIPAA standards transactions and code sets.
a. More reliable and timely processing - quicker reimbursement from player b. improved accuracy of data c.easier and more efficient access to information c. better tracking of transactions d. reduction in office expenses
