Chapter 9: Billing

Question 1

Which regulation established claim standards for electronic filing requirements when a provider uses a computer with software to submit an electronic claim?

Answer 1

Health Insurance Portability and Accountability Act (HIPAA)

Question 1

What documentation is needed for an audit?

Answer 1

• Patients medical record
• CMS 1500 Claim form
• encounter form (ov note)

Question 2

What is a claim scrubber?

Answer 2

a software program that reviews claims for key components before the claims are sent to an insurance company
- Data entry errors
- verifies CPT, HCPCS, and ICD 10 codes
- can verify that ICD10 codes support medical necessity for LCD/NCD and identify bundled services

Question 3

Mrs. Jones went in for a surgical procedure and the claim was denied because the office did not obtain prior authorization. The carrier does not allow authorizations to be obtained after the procedure has been performed. What is done to recover any payment?

Answer 3

the provider is required to write off the balance
- the patient is not responsible for payment if the PA was not obtained

Question 4

What is a master price list of every single procedure, service, supplies, devices, and medications that a hospital can provide to its patients that are billed to payers?

Answer 4

Chargemaster/ Charge description master (CDM)