Chapter 27: Preparing Insurance Claims and Posting Insurance Payments Flashcards
Administrative Simplification Compliance Act (ASCA)
identifies limited situations where paper claim forms may be submitted for payment (rather than electronic submission); signed into law on December 27, 2001, as Public Law 107-105
Centers for Medicare and Medicaid Services (CMS)
previously known as the Health Care Financing Administration (HCFA), CMS is the federal agency within the U.S. Department of Health and Human Services (HHS) responsible for administration of several key federal health care programs (Medicare and Medicaid)
clearinghouse
a private or public company that often serves as the middleman between physicians and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers
crossover claim
a claim that is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service
electronic claims tracking (ECT)
computer software designed for monitoring insurance claims
electronic data interchange (EDI)
refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols
electronic media claims (EMC)
a flat file format used to transmit or transport claims
national provider identifiers (NPI)
the name of the standard unique health identifier for health care providers
scrub
(1) claim scrubbing ensures that claims are correctly coded before being sent to the insurance company, which reduces denials and increases payments to the practice; (2) specific and thorough hand-washing procedure performed for six minutes before taking part in any sterile surgical procedure
secondary insurance
exists when a patient is covered under more than one insurance plan; charges are first submitted to the primary carrier, and any charges not covered are then submitted to the secondary carrier
