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Chap 7/8

CMS - EDI

QuestionAnswer
when to bill NO charges always bill NO charges
entering data for OCR claims capital letters, no punctuation, procedure & diagnotic codes, leave blocks blank that do not apply
when do you submit documentation only when requested
how are paper claims submitted on paper, through the mail, and then optically scanned
how are electronic claims submitted through the internet
agreement for electronic claims submission signed agreement by the physician & carrier
funtions of a clearinghouse known as TPA (third party administrator), software edit checks, sorts and transmits claims, and receives the ERA back from the insurance company
NEIC systems provides national network that allows physcians to use one version to communicate; also known as the clearinghouse
provider number used on the insurance claim form NPI (national provider identification)
two ways claims can be transmitted electronically 1. carrier direct (from doctor directly to insurance company) 2. clearinghouse
dual coverage patient has 2 private insurance policies
where is insurance companies name and address listed on the claim form top right hand side
two sections of a claim form 1. patient insured (top half) 2. physcian and supplier (bottom half)
how many locations for diagnostic codes can be listed on the claim form 4
digital signature indicates a signature has been attached from within the software application
networks computers that are interconnected to exchange information
clearinghouse entity that receives transmissions of claims from the physcian office
rejected claim claim that needs further clarification, possible investigation, and answers to questions
clean claim claim submitted with the program or policy time limit and contains all necessary information
pending claim claim held in suspense while being reviewed or additional information is requested
incomplete claim claim missing information
CMS-1500 universal claim form
Created by: maxphia32
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