Ch. 7 Terms Flashcards
Paper claim
Submitted on paper including optically scanned claims that are changed to electronic form by insurance companies. Paper claims may be typed or generated via computer. Paper submissions and non participating provider claims are not processed until at least 27 days after receipt.
Electronic claim
Submitted to the insurance carrier by a dial up modem (telephone line or computer modem), direct data entry, or over the internet by way of Digital Subscriber Line (DSL) or File Transfer Protocol (FTP). Electronic claims are digital files that are not printed on paper claim forms when submitted to the payer. It takes about 14 days to process after receipt.
Clean claim
Claim is submitted within the program or policy time limit and contains all necessary info so that it can processed and paid promptly.
Physically clean claim
Has no staples or highlighted areas and on which the bar code has not been messed up.
Rejected claim
Hasn’t been processed or can’t be processed for various reasons . It requires research and should be resubmitted after proper corrections are made.
Pending claim
Held in suspense for review or other reason by the third party payer. These claims may be cleared for payment or denied.
“Other claims”
Medicare claims not considered “clean”, which requires investigation or development on a prepayment basis (developed for Medicare Secondary Payer information).
Incomplete claim
Missing required info. It’s identified to the provider so that it can be resubmitted as a new claim.
Invalid claim
Contains complete, necessary info but is illogical or incorrect (ex: listing an incorrect provider number for a doctor). An invalid claim is identified to the provider and may be resubmitted.
Dirty claim
Submitted with errors, one requiring manual processing for resolving problems, or one rejected for payment. Pending or suspense claims are placed in this category because something is holding the claim back from payment, perhaps review or some other problem.
Deleted claim
Canceled, deleted or voided by a Medicare fiscal intermediary for the following reasons :CMS 1500 or current CMS 1450 isn’t used, itemized charges aren’t provided, more than six line items are submitted on the CMS 1500 claim form, patient’s address is missing, internal clerical error was made, Certificate of Medical Necessity (CMN) was not with the Part B claim or was incomplete or invalid, and name of the store isn’t on the receipt that includes the price of the item.
Health Insurance Claim form (CMS-1500 [08-05])
Often known simply as the CMS-1500 claim form, is the form required when submitting Medicare claims and is accepted by nearly all state Medicaid programs and private third party payers, as well as by TRICARE and workers’ compensation.
State license number
To practice within a state, each doctor must obtain this license. Sometimes this number is requested on forms and is used as a provider number.
Employer Identification Number (EIN)
Each doctor must have his own federal tax identification number or tax identification number (TIN). This is issued by the internal revenue service for income tax purposes.
Provider numbers
Claims may require several NPI numbers: one for the referring doctor, the ordering doctor, and one for the performing doctor.
