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Billing and Coding
Chapter 7 Terms
| Question | Answer |
|---|---|
| 5010A1 Version | |
| Administrative Code Set | Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes. |
| Billing provider | The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to provider who receives payment. |
| Carrier block | Data entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer. |
| Claim attachment | Documentation that a provider sends to a payer in support of a healthcare claim. |
| Claim Control Number | Unique number assigned to a healthcare claim by the sender. |
| Claim filing indicator code | Administrative code used to identify the type of health plan. |
| Claim Frequency Code (Claim Submission reason code) | Administrative code that identifies the claim as original, replacement, or void/cancel action. |
| Claim Scrubber | Software that checks claims to permit error correction for clean claims. |
| Clean Claim | A claim that is accepted by a health plan for adjudication. |
| CMS-1500 | Paper claim for physician services. |
| CMS-1500 (02/12) | Current paper claim approved by the NUCC. |
| Condition Code | Two-digit numeric or alphanumeric code used to report a special condition or unique circumstance about a claim; reported in Item Number 10d on the CMS-1500 claim form. |
| Data element | The smallest unit of information in a HIPAA transaction. |
| Destination Payer | In HIPAA claims, the health plan receiving the claim. |
| Healthcare Provider Taxonomy Code (HPTC) | Administrative code set used to report a physician’s specialty. |
| HIPAA X12 837 Health Care Claim: Professional (837P) | Generic term for the HIPAA X12N 837 professional healthcare claim transaction. |
| HIPAA X12 276/277 Health Care Claim Status Inquiry/Response | The HIPAA X12N 276/277 transaction in which a provider asks a health plan for information on a claim’s status and receives an answer from the plan. |
| Individual Relationship Code | Administrative code that specifies the patient’s relationship to the subscriber (insured). |
| Line item control number | On a HIPAA claim, the unique number assigned by the sender to each service line item reported. |
| National Uniform Claim Committee (NUCC) | Organization responsible for the content of healthcare claims. |
| Other ID number | Additional provider identification number supplied on a healthcare claim. |
| Outside Laboratory | Purchased laboratory services. |
| Pay-to provider | The person or organization that is to receive payment for services reported on a HIPAA claim; may be the same as or different from the billing provider. |
| Place of service (POS) code | HIPAA administrative code that indicates where medical services were provided. |
| Qualifier | Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI). |
| Rendering Provider | Term used to identify the physician or other medical professional who provides the procedure reported on a healthcare claim if other than the pay-to provider. |
| Required Data Element | Information that must be supplied on an electronic claim. |
| Responsible Party | Person or entity other than the insured or the patient who will pay a patient’s charges. |
| Service Line information | On a HIPAA claim, information about the services being reported. |
| Situational Data Element | Information that must be supplied on a claim when certain other data elements are provided. |
Created by:
t_talks
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