B&C Chapter 11: CMS-1500 and UB-04 Claims Flashcards
ANSI ASC X12N 837I
standard format for submission of electronic claims for institutional health care services.
ANSI ASC X12N 837P
standard format for submission of electronic claims for professional health care services.
billing entity
the legal business name of the provider’s practice.
data packets
Format of electronic claims transmission, where are routed between provider and billing company, clearinghouse, or payer using the Internet or other packet-exchange network.
diagnosis pointer letters
item letters A through L preprinted in Block 21 of the CMS-1500 claim.
Federal Privacy Act
enacted in 1974 to prohibit a payer from notifying the provider about payment or rejection of unassigned claims or payments sent directly to the patient or policyholder.
hospitalist
dedicated inpatient physician who works exclusively in a hospital.
Medicare supplemental plan
covers the Medicare deductible and copay or coinsurance amounts that patients pay for receiving health care through Medicare.
National Council for Prescription Drug Programs (NCPCP) Telecommunication Standard
standard format for retail pharmacy.
National Plan and Provider Enumeration System (NPPES)
developed by CMS to assign unique identifiers to health care providers (NPI).
supervising physician
a licensed physician in good standing who, according to state regulations, engages in the direct supervision of nurse practitioners and/or physician assistants whose duties are encompassed by the supervising physician’s scope of practice.
UB-04
insurance claim or flat file used to bill institutional services, such as services performed in hospitals.
