Insurance Handbook – Chapter 8

1) **Fill-in Question** Define encryption
is used for security purposes to assign a code to represent data. It is a “secret code” that makes data unintelligible to unauthorized parties.
2) Why are electronic transmissions encrypted?
so that they cannot be opned and read if intercepted (received) by the wrong individual.
3) Define batch
is a group of claims for different patients sent at the same time from one facility.
4) When can payments be received after electronic transmissions?
in 2 weeks or less
5) What is an important advantage of the electronic claims submission?
the on-line error-edit process that may be incorporated into the software in the physician’s office, clearinghouse, or insurance company.
6) Define clearinghouse
is an entity that receives the electronic transmission of claims (EDI) from the health care provider’s office and translates into a standard format in HIPAA regulations.
7) What are the clearinghouse’s duties?
to separate the claim by carrier, perform software edits on each claim to check for errors, and to transmit claims electronically to the correct insurance payer.
8) Under HIPAA, what circumstances would likely make a provider a covered entity and therefore they must comply with HIPAA compliance?
1) if the provider submits electronic transactions
2) Large providers: if the provider submits paper claims to Medicare and has 10 or more employees.
9) What is a benefit of TCS (HIPAA Transaction and Code Set) and EDI (Electronic Data Interchange)?
fast eligibility evaluation (reduce time of claim life cycle) and improves cash flow.
Average turnaround for electronic claims are 9-15 days versus 30-45 days for paper claims.
10) Under HIPAA, what circumstances would likely NOT make a provider a covered entity?
1) If the provider has fewer than 10 employees and submits only paper claims to Medicare.
2) if the provider only submits paper claims until and after April 14, 2003 and does not send claims to Medicare
11) Define Code Sets
they are allowable sets of codes that anyone could use to enter information into a specific space (field) on a form.
12) Medical codes are what?
data elements
13) How are data elements used?
uniformly to document why patients are seen (diagnosis, ICD-9-CM) and what is done to them (procedure, CPT-4 & HCPCS) during their encounter.
14) What is an EIN?
employer identification number assigned by the IRS (Internal Revenue Service)
15) What is an EIN used for?
to identify employers for tax purposes.
16) In 837P Data elements: Insured Name (Last, First, Middle) are what?
17) What is the most important function of a Practice Management System?
Accounts Receivable
18) What is a PMS?
Practice Management System
19) What are other names for an encounter form?
1) charge slip 2) multipurpose billing form
3) Patient service slip 4) routing form
5) super bill 6) transaction slip
20) What is an encounter form?
a document used to record information about the services rendered to a patient.
21) **Fill-in Question** What is a prompt?
a question asked (on the screen) in which you key in a response
22) What is the first “DO” when keying in data and billing electronic claims?
use the patient’s account number to differentiate between patients with similiar names
23) What is the second “DO” when keying in data and billing electronic claims?
use correct numeric service location codes, current valip CPT codes, or Healthcare Common Procedure Coding System (HCPCS) procedure codes.
24) What is the third “DO” when keying in data and billing electronic claims?
print an insurance billing worksheet or perform a front-end edit (on-line error checking) to look for errors and correct them before submitting the claim to the third-party payer.
25) What is the fourth “DO” when keying in data and billing electronic claims?
request electronic-error reports from the third-party payer to make corrections to the system.
26) What is the last “DO” when keying in data and billing electronic claims?
obtain and cross-check the electronic status report against all claims transmitted.
27) What is the first “DON’T” when keying in data and billing electronic claims?
use special characters (dashes, spaces, or commas)
28) What is the last “DON’T” when keying in data and billing electronic claims?
bill codes using modifiers -21 or -22 electronically (unless the carrier receives attachments) to justify more payment.
29) During the edit and error process, software code indentify what?
invalid codes, age conflicts, gender conflicts, procedural and diagnostic code conflicts, and other data before issuing payments.
30) What is an encoder?
is an add-on software to practice management systems that can greatly reduce the time it takes to build or review a claim before batching.
31) When using an encoder: the billing specialist or other user is prompted with what?
with a series of questions or choices leading to pr affecting a specific code assignment by displaying code-specific edits.
32) For assignment of benefits, what must be obtained?
each patient’s signature. The signature must be obtained and retained in the office records because there are no handwritten signatures on electronic claims.
33) What is Interactive Transaction?
is back-and-forth communication between two computer systems.
34) **Fill-in Question** What is an ERA?
Electronic remittance advice – an online transaction about the status of a claim.
35) What information does the ERA give?
information on charges paid or denied.
36) Date entry is not required in an ERA if?
the medical practice elects to get the software system to automatically post the information to patients’ accounts
37) What system do fiscal agents such as Medicaid, Medicare, TRICARE, and many private third-party payers use?
the carrier-direct system
38) How does the carrier-direct system work?
the data is transmitted electronically, directly into the payer’s system which eliminated the need for a clearinghouse.
39) How do clearinghouses charge?
may charge a flat rate per claim or a monthly charge.
40) Regardless of submission through carrier-direct or a clearinghouse reports are generated and accessible to do what?
track each function of the claims process.
41) Define scrubber report
indicates the total number of claims, charges, and dollar amounts that were received by the clearinghouse and scrubbed to Massachusetts Insurance Plan.
42) When claims have been submitted through the clearinghouse, the billing specialist does what?
review the scrubber report for each insurance payer
43) What do security measures encompass?
all the administrative, physical, and technical safeguards in an information system.
44) What does the Security rule address?
only electronic protected health information (ePHI) but the concept of protecting PHI (which becomes ePHI) puts emphasis on security for the entire office.
45) The security rule is divided into what three sections?
1) Administrative safeguards
2) Technical safeguards
3) Physical safeguards
46) **Fill-in Question** What do administrative safeguards do?
they prevent unauthorized use or disclosure of PHI through administrative actions that manage the selection, development, implementation, and maintenance of security measures to protect ePHI.
47) Administrative safeguards – management controls do what?
guard data integrity, confidentiality, and availability.
48) Administrative safeguards include what?
internal audits which allow the ability to review who has had access to ePHI to ensure there is no intentional or accidental inappropriate access (in PMS and paper records or charges).
49) **Fill-in Question** What are technical safeguards?
technological controls in place to protect and control access to information on computers in health care organization.
50) Technical safeguards include what?
automatic payoffs to prevent unauthorized users from accessing a computer when it is left unattended.
51) **Fill-in Question** What do physical safeguards do?
prevent unauthorized access to PHI. These physical measures and P protect a covered entity’s electronic information systems and related building and equipment from natural and unauthorized intrusion.
52) Physical safeguards policies include what?
how the office handles the retention, removal, and disposal of paper records, as well as recycling of computers and destruction of obsolete data disks or software programs containing PHI.
53) **Fill-in Question** Define Backup
means to save data frequently (preferably daily). a duplicate data file which may be used to complete or redo the operation if the primary equipment fails.
54) **Fill-in Question** Define password
a combination of letters and numbers that each individual is assigned to access computer data. Passwords should be changed at regular intervals and never written down.
55) **Fill-in Question**
The person who is responsible and accountable
56) **Matching** Daily Guidelines and Protocols
1) Post charges in PMS (2) Post Payments in PMS
3) Batch, scrub, edit, and transmit claims; retrieve transmission reports (4) Run day sheet (5) Review clearinghouse/payer transmission confirmation reports
6) Audit claims batched and transmitted with confirmation reports. (7) Correct rejections and resubmit claims
57) **Matching** Weekly Guidelines and Protocols
1) Batch, scrub, edit, and transmit claims; retrieve transmission reports (2) Analyze previous weeks rejected and resubmitted claims (3) Note any problematic claims and resolve outstanding files (4) Research unpaid claims.
5) Make follow-up calls to resolve reasons for rejections (such as incorrect NPI, missing patient ID, incomplete data elements and wrong format).
58) **Matching** Monthly Guidelines and Protocols
1) run month-end aging report
2) Review all claim rejection reports (clearinghouse and payer), making sure all problems are resolved and claims accepted (3) update PMS with payer information (such as EIN and NPI). (4) Run patient statements in office or through clearinghouse
59) Where should backup files be stored?
copies should be placed away from the office in case of fire, flood, or theft.
60) BMT?
Bone Marrow Transplantation
61) BSE?
Breast Self-Examination
62) cc?
cubic centimeters
63) AP?
64) AUB?
Abnormal Uterine Bleeding
65) C?
Carbon or Calorie
66) c/o?
Complaint of
67) @?
68) BSO?
Bilateral Salphingoorphorectomy