ANSI X 12 Flashcards

1
Q

ANSI

A

American National Standards Institute

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2
Q

SDO

A

Standards Development Organization

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3
Q

X12N Standards

A

All covered entitites must comply

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4
Q

Organizations sending the 277 Health Care Claim Status Response include:

A

Insurance Companies
Third Party Administrators (TPAS)
Service corporations
State and Federal agenices and their contractors
Plan purchasers
Any other enitty that processes health care claims

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5
Q

Other businesses affiliated with 277

A

Billing Services
Consulting Services
Vendors of payments
EDI network intermediaries, such as automated clearinghouses, value-added network, and telecommunication services.

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6
Q

A transaction 277 response may include

A
Accepted/rejected claim status
Claim pending-incorrect/incomplete claim or supended claim
Final: Rejected claim
Final: Denied claim
Final: Approved claim pre-payment
Final: Approved claim post-payment
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7
Q

Who posts a 277 Transaction

A

Insurance companies, intermediaries, government agencies and auditors, or billing agents and services.

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8
Q

Who performs the Acknowledgement

A

The Acknlowledgement is often perfomed by the ANSI 996 Functional Acknolwedgment Transaction. This transaction isn’t a HIPAA Standard. Howerver, itf commerce and effcieincy are best served by usiting it, trading partners are free to do so. However, the 997 may not be used for a function otherwise supported by an approved standard transaction such as the 277.

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9
Q

278 Certification and Authorization Referral and the request for Review and Response.

A

are used to transmit referral information between providers and bettween provider and payer. They’r also used for pre-certification, concurrent review, and other utilization management information. NOTE: Referral from provider to provider is the most attractive transaction for providers.

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10
Q

Events covered by 278 Transaction

A

Admisstion certification review and request and response
Health care services certification review request and response
Extend certification review request and response
Authroication of services, service levels, or service extensions

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11
Q

Terms used in a 278 review transaction

A
Long-term care
Patient Event
Requester
Service Provider
Utilization Management Organization (UMO) or Insurer
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12
Q

How to issues addressed by the 278 differ from those for the 276?

A

The Certiffication and Authorization of Refferrals Request for Review triggers and audit of a request for services or health care encounter and the forms, conditions, certfications, and adjudication arising from it. The requster is a provider who seeks authorization or certificaiton for a patient to recieve health care services.

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13
Q

The 278 trading partners - unsolicitated

A

The 278 transaction can be used to send unsolicited information to trading partners. this data can take the form of health service review copies, authroication approval, or notification of the beginning or end of treatment.

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14
Q

278 Trading Partner Events

A

Patient arrival notice
Patient discharge notice
Certification or service change notice
Notification of certification or authorization to the primary provider, other providers, and UMOs

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15
Q

278 Transaction Flow for 278

A

Used to transmit information pertinent to subsrciber or patient identificaiton,demographics, treatment/diagnosis, or certification of provided or proposed services in response to a 278 health care services request for review.

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16
Q

820-Health Plan Premium Payments

A

also known as the “Transaction supporting Payroll Deducted and Other Group Premium Payment for Insurance Products.” It is used to pay for insurance products (individual and group premiums), to forward remittance advice associiated with those payments, or both.

17
Q

820-Payment form

A

a transaction order to a financial institution or directions to a payee’s accounts receivable system. And/or premium paytments to an insurance carrier.

18
Q

EFT

A

Electric Funds Transfer, transactions that are fully supported through submission of the 820.

19
Q

820 Applicable transactions

A

Sending premium payments to:
Insurance company
Health care organization
Government Agency

20
Q

Who initiates an 820 transaction

A

an employer or sponsor

21
Q

820 and HIPAA

A

In 2013, the 820 transaction was formally adopted as a standard uner HIPAA for health care EFT and remittance advice (RA) transactions, with an effective implementation date of January 1, 2014.

22
Q

1st HIPAA use of EFT/820

A

with remittance information carried throughthe Automated Clearinghouse (ACH) system. The choice of which type of detail is follawed by the contract type:
Organization summary remittance detail
Individual remittance detail

23
Q

2nd HIPAA use of EFT/820

A

the use of an EFT or a check to make the premium payment, with separate remittance advice containing information for either of the following.
Organization summary remittance detail
Individual remittance detail

24
Q

820 and Banks

A

The movement of remittance advice is through 820 transaction communicated outside of the banking networks. The choid of detail detail depends on the contract.
The 820 can be sent to the bank:
To move money only
to move money as well as detailed or summary remittance information.

25
Q

820 and PAYEE

A

The 820 transaction can also be sent directly to a payee to move detailed or summary remittance information.

26
Q

Remittance Advice

A

is intended to support automatic reconciliation of premiums in a health plan’s accounts receivable systems and is one of the msot attractive transactions from a health plan’s viewpoint.

27
Q

834-Enrollement or Disenrollemnt in a Health Plan

A

the 834 transaction is used to transfer enrollment information from a sponsor to a health care insurance or benefit provider. the sponsor is the employer, associateo, or other agency that ulitmately pays for the insurance cov

28
Q

Sponsor

A

The sponsor is the employer, association, or other agency that ultimately pays for the insurance coverage. The sponsor may also elect to designate a Third Party Administrator (TPA) to submit the information.

29
Q

834 - Transfer

A

the 834 is used to transfer enrollment information from the sponosr of the health care insurance coverage, benefits, orpolicy to a health company.

30
Q

834-Use

A

This transaction is used to enroll, update, or disenroll employees and dependents in a health plan. The transaction is typically used in two modes” update and full replacement

31
Q

834-update mode

A

The employer, union, or other sponsor sends transactions to add, change, or temrinate subscriber and dependent records.

32
Q

834-Full replacement mode

A

The sponsor periodcially send a complete file of all subrsibers and dependents, and the payer does a comparison and reconciliation with its files. The enrollment transaction is expected to be popular with large accounts. Onlice screen services may be more popular with small and medium size accounts.

33
Q

834 - Parties that engage in enrollment process

A
Sponsor
Payer/insurer 
Third Party Administrator (TPA)
Subscriber
Dependent
Insured or member