Chapter 8 The Electronic Claim

Accredited Standards Committee X12
The United States standards body formed by the American National Standards Institute (ANSI) for cross-industry development, maintenance, and publication of electronic data exchange standards.
Accredited standards Committee X12 Version 5010
System developed by the American National Standards Institute that meets HIPAA standards for the transmission of either ICD-9 or ICD-10 diagnostic code data.
application service provider
A practice management system available over the internet in which data are housed on the server of the ASP, but the accounts are managed by the health care provider’s staff.
back up
A duplicate data file, such as tape, CD-ROM, disk, or zip disk, used to record data; it may be used to complete or redo the operation if the primary equipment fails.
A group claims for different patients from one office submitted in one computer transmission.
business associated agreement
Contract between the provider and a clearinghouse that submits the electronic claims on behalf of the provider.
cable modem
A modem used to connect a computer to a cable television system that offers online services.
claim attachments
Documents that contain information, hard copy or electronic, related to a completed insurance claim that assists in validating the medical necessity or explains the medical service or procedure for payment (e.g., operative report, discharge summary, invoice).
a service company that recieves electronic or paper claims from the provider, checks and prepares them for processing, and transmits them in HIPAA-complaint format to the correct carriers
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.
covered entity
same as definition in Chapter 2
data elements
Medical code sets used uniformly to document why patients are seen (diagnosis, ICD-9-CM) and what is done to them during their encounter (procedure, CPT-4, HCPCS).
digital subscriber line
A high-speed connection through a telephone line jack and usually a means of accessing the Internet.
direct data entry
Keying claim information directly into the payer system by accessing over modem dial-up or DSL. This is a technology to directly enter the information into the payer system via the access whether it is dial-up or DSL.
electronic data interchange
The process by which understandable data items are sent back and forth via computer linkages between two or more entities that function alternatively as sender and receiver.
electronic funds transfer
A paperless computerized system enabling funds to be debited, credited, or transferred, eliminating the need for personal handling of checks.
electronic remittance advice
An online transaction about the status of a claim.
clearing house
Software that receives insurance claims from the providers; performs, edits and sends them to the insurance carriers.
An add-on software program to practice management systems that can reduce the time it takes to build or review insurance claims before batch transmission to the carrier.
National Standard Format
The name of the standardization of data to reduce paper and have more accurate information and efficient organization.
HIPAA Transaction and Code Sets Rule
This regulation under Health Insurance Portability and Accountability Act (HIPAA) 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.
A combination of letters and numbers that each individual is assigned to access computer data.
real time
Online interactive communication between two computer systems allowing instant transfer of information.
standard transactions
The electric files in which medical data are compiled to produce a specific format.
A T-carrier channel that can transmit voice or data channels quickly.
taxonomy codes
Numeric and alpha provider specialty codes that are assigned and classify each health care provider when transmitting electronic insurance claims.
trading partner
same as definition for Business associate in Chapter 2
To assign a code to represent data. This is done for security purposes.
trading partner agreement
Contract between the provider and a clearinghouse that submits the electronic claims on be half of the provider.
American National Standards Institute
Accredited Standards Committee X12
administrative simplification enforcement tool
application service provider
automated teller machine
direct data entry
Department of Health and Human Services
Digital Subscriber Line
electronic data interchange
electronic funds transfer
electronic health record
electronic medical claim
explanation of Medicare benefits
electronic protected health information
electronic remittance advice
Health Plan Identifier
Internal Revenue Service
Medicare Transaction System
National Drug Code
National Standard Format
practice management software
TCS Rule
HIPAA Transaction and Code Set Rule
Uninterruptible Power Source
Exchange of data in a standardized format through computer systems is a technology known as..
Electronic Data Interchange (EDI)
The act of converting computerized data into a code so that unauthorized users are unable to read it is a security system known as….
Payment to the provider of service of an electronically submitted insurance claim may be received in approximately…
Two Weeks or Less
Medical Practices that do not use the services of clearinghouses submit claims through a ____to the insurance company…
Carrier-Direct/Direct Links
The benefits of using HIPAA standard transaction and code set
A).Translations of various formats to the HIPAA-complaint standard format
B).Reduction in time of claims preparation
C).Fewer Claim Rejections
D).Cost-Effective method through loss prevention’
E).Fewer delays in processing and quicker response time
F).More accurate coding with claims edits
G).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-Compliance is Required
Dr. Maria Montez does not submit insurance claims electronically and has five full-time employees. Is she required to abide by HIPAA transaction rules?
It is not required to comply
Standard Code Sets used for the following….

)( Physician Services)-(CPT), Current Procedural Terminology

(Diseases and Injuries)-International Classification of Diseases, Ninth Revision, Clinical Modifications, Volumes 1 and 2 (ICD-9-CM)

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(Pharmaceuticals and Biologicals)-National Drug Code (NDC)

The staff at College clinic submits professional health care claims for each of their providers and must use the industry standard electronic format called_______________ to submit them electronically
ASC X12N 837P
The billing department at college clinic must use the industry standard electronic format called ___________ to transmit health care claims electronically
ASC X12N 837I
The Medicare fiscal intermediary (insurance carrier) uses the industry standard electronic format called____to transmit payment information to the college clinic and college hospital.
ASC X12N 835
It has been 3 weeks since Gordon Marshall’s health care claim was submitted to the XYZ insurance company and you wish to inquire about the claim.The industry standard electronic format that must be used to transmit this inquiry is called_________
ASC X12N 276/277
Dr.Practons insurance billing specialist must use the industry standard electronic format called __________to obtain information about beatrice garcia’s health policy benefits and coverage from the insurance plan.
ASC X12N 270/271
The family practice taxonomy code is..
The American National Standards Institute formed the___which developed the electronic data exchange standards.
Refer to table 8-4 in the handbook to name the levels of data collected to construct and submit a electronic form
High-level information
Claim-level information
Specialty claim-level information
Service line-level information
Specialty service line-level information
Other information
HIPAA electronic standards for claim submission were upgraded to version ________ and all providers,payers, and clearinghouses were required to use it effective January 1, 2012
The claims attachment standards have not yet been adopted;however the health insurance specialist should prepare for the final rule that is expected to be published no later than __________
January 1, 2014
The _______ is an all numeric 10-character number assigned to each provider and required for all transactions with health plans effective May 23, 2007
The most important function of a practice management system is _________
accounts receivable
To look for and 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 audit or
much of the patient and insurance information required to complete the cms-1500 form can be found on the ___________ form that is used to post charges.
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
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
Many insurance companies, such as Medicare, provide instant access to information about pending claims though online _______________
ERA-electronic remittance advice
An electronics funds transfer agreement may allow for health plans to ___________ overpayments from a provider’s bank account.
The medicare electronic remittance advice was previously referred as a/an _________________________
EOMB-explanation of medicare benefits
On completion of a signed agreement and approval of enrollment with a third party payer for electronic claims submission, the provider will be assigned a ________________________ number.
When computer software is upgraded, the physician must submit a batch of ___________________ to the insurance carrier to determine if claims can be transmitted successfully.
test files
Under HIPAA transaction standard ASC X12 version 5010,a _____________ digit zip code is required to report service facility locations.
The ________________________________ is a electronic tool that enables organizations to file a complaint against a noncompliant covered entity that is negatively impacting the efficient processing of claims.
Access controls allow organizations to create _____________ for each job category that will restrict access to certain data.
Under HIPAA, ________________ efforts must be made to limit the use and disclosure of PHI.
Electronic claims are submitted by means of
Today most claims are submitted by means of
The online error process allows providers to
correct claim errors prior to transmission of the claim
Under HIPAA, data elements that are use uniformly to be documented why patients are seen (diagnosis) and what is done to them during their encounter(procedure) are known as
medical code sets
The standard transaction that replaces the paper cms-1500 (02-1200) claim form and more than 400 versions of the electronic national standard format is called the
The next version of the electronic claims submission that will be proposed for consideration once lessons are learned from implementation of version 5010 will be
version 6020
A standard unique number that will be assigned to identify individual health plans under the affordable care act is referred to as an
Uniform patient identifiers
were required on all claims effective may 23 2007
Encounter forms should be reviewed annually for changes that may have been made to
diagnosis codes
procedure codes
HCPCS codes
A technique for entry of data which can save time and keystrokes by recording commands into memory is referred to as use of
An authorization and assignment of health benefits signature for a patient who was treated in the hospital but has never been to the providers office
is not required;the authorization obtained by the hospital applies to that provider’s claim filing.
A paperless computerized system that enables payments to be transferred automatically to a physician’s bank account by a third party payer may be done via
EFT-electronic funds transfer
An electronic Medicare remittance advice that takes the place of a paper medicare explanation of benefits (EOB) is referred to as
ANSI 835
A method for submitting claims electronically by keying information into the payer system for processing is accomplished through use of
direct data entry-DDE
A report that is generated by a payer and sent to the provider to show how many claims were received as electronic claims and how many were automatically rejected and will not be processed is called an
transaction transmission summary
The HIPAA transaction standard ASC X12 version 5010 requires that anesthesia services be reported
per minute
Which section of the HIPAA security rule recommends unique usernames and passwords to log on to any computer with access to PHI?
technical safeguards
Which section of the HIPAA security rule recommends use of screensavers that will activate 1 to 60 minutes of inactivity
physical safeguards
Verification of successful backups by comparing original records with copied records should be performed
once a week
An acceptable method for ensuring that ePHI cannot be recovered from a hard drive that is being disposed of is by
deletion of files
formatting hard drives
Like paper claims electronic claims require the performing physicians signature
Claims must be submitted to various insurance payers in a single batch electronic transmission
under hipaa insurance payers can require health care providers to use the payers own version of local code sets
as icd and cpt codes are deleted and become obsolete they should immediately be removed from the practices computer system
hipaa has brought forth electronic formats for determination of eligibility for a health insurance plan
hipaa’s electronic standard transactions are identified by a four digit number that proceeds asc x12n
implementation of icd-10 resulted in a upgrade to hipaa transaction standard asc x12 version 6020
hipaa requires that the npi number be used to identify employers rather than inputting the actual name of the company when submitting claims
hipaa limits how computer systems may transmit data and formats for storage of data
a paper remittance advice is generated by medicare when using ansi 835 version 5010
hipaa transaction standard asc x12 version 5010 allows employers identification numbers to be used to report as a primary identifier
when transmitting electronic claims inaccuracies that violate the hipaa standard transaction format are known as syntax errors
an organization may file a complaint online against someone whose actions impact the ability of a transaction to be accepted or efficiently processed by using the administrative simplification enforcement tool (ASET)
incidental uses and disclosures of protected health information(PHI) are permissible under hipaa when reasonable safeguards have been used to prevent inappropriate revelation of phi
deleting files or formatting the hard drive is sufficient to keep electronic protected health information from being accessed

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Chapter 8 The Electronic Claim. (2018, Jan 15). Retrieved from