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Compliance > HIPAA Lesson 3 > Flashcards

HIPAA Lesson 3 Flashcards

1
Q

A ________ is the exchange of information between two parties to carry out financial or administrative activities related to healthcare.

A

Transaction

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2
Q

A ________ is any group of codes used for encoding data elements.

A

Code Set

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3
Q

A ________ is a combination of letters and numbers that providers, health plans, and employers use to uniquely identify themselves within a transaction.

A

National Identifier

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4
Q

A ________ clearly defines the data elements that make up a single transaction and the order in which they appear.

A

Transaction Standard

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5
Q

270 Health Plan Eligibility Inquiry

A

Providers verify insurance eligibility and benefits electronically - What type of coverage does the patient have?

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6
Q

271 Health Plan Eligibility Response

A

Providers receive an electronic response to an insurance eligibility inquiry - Reply to a 270 request.

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7
Q

276 Healthcare Claim Status Request

A

Providers check the status of an insurance claim electronically - Has the claim been processed yet.

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8
Q

277 Healthcare Claim Status Response

A

Providers receive an electronic response to an insurance claim status inquiry - Reply to a 276 Request.

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9
Q

Certification and Authorization of Referrals—Request for Review: Providers get authorization for referrals electronically.

A

278

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10
Q

278 Certification and Authorization of Referrals—Response

A

Providers get a response to a request for a referral authorization - Precertifying a patient for surgery.

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11
Q

280 Health Plan Premium Payments

A

An insured party makes an electronic payment of health plan premiums - Employer payment to health plan.

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12
Q

834 Enrollment or Disenrollment in a Health Plan

A

An insured party electronically enrolls into or out of a health plan - Update employees in a heath policy.

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13
Q

835 Healthcare Claim Payment/Remittance Advice

A

An insurance claim payer responds with payment and an itemized (detailed) remittance statement - Explanation of benefits to a provider.

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14
Q

837 Healthcare Claim

A

A physician’s office files an insurance claim electronically using this format. The CMS-1500 is the hard copy (paper) version. (A provider’s claim)

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15
Q

Healthcare Claim—Dental: A dentist’s office files an insurance claim electronically using this format. The hard copy (paper) version is the American Dental Association form.

A

837

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16
Q

Healthcare Claim—Institutional: A hospital files an insurance claim electronically using this format. The UB-04 (CMS-2450) is the hard copy (paper) version.

A

837

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17
Q

If a provider submits a standard ________, a health plan must be able to receive it. And that health plan can’t in any way delay processing of a standard ________.

A

Transaction

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18
Q

TPA

A

Third-Party Administrator

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19
Q

Processes, pays, and settles (or adjudicates) claims.

A

TPA

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20
Q

275 Healthcare Claims Attachment

A

The organization called HL7 sets the standards for claims attachments. This standard can capture all sorts of data in electronic form. It can carry multiple formats, including binary and image data. We can use it to send photographs, X-rays, and many other types of multimedia information. The other standards are strictly for sending text.

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21
Q

A ________ is any group of codes used for encoding data elements.

A

Code Set

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22
Q

________ include tables of terms, medical concepts, medical diagnostic codes, and medical procedure codes.

A

Data Elements

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23
Q

ICD-10-CM

A

International Classification of Diseases, 10th revision, Clinical Modification

24
Q

CPT

A

Current Procedural Terminology

25
Q

CDT

A

Code on Dental Procedures and Nomenclature

26
Q

ICD-10-PCS

A

International Classification of Diseases, 10th revision, Procedural Coding System

27
Q

NDC

A

National Drug Code

28
Q

HCPCS

A

Healthcare Common Procedure Coding System, Level II

29
Q

This code set describes or identifies codes for diseases, injuries, impairments, and other health-related problems and their manifestations.

A

ICD-10-CM

30
Q

This is the code set for describing or identifying physician services or procedures, and the American Medical Association is responsible for updating. The codes include physician services, physical and occupational therapy services, and radiological procedures. They also cover clinical laboratory tests, medical diagnostic procedures, and hearing and vision services.

A

CPT

31
Q

This code set is used to describe or identify dentist services or procedures. The American Dental Association owns the code set and is responsible for updating.

A

CDT

32
Q

The code set that you’d use to describe or identify inpatient hospital services and surgical procedures. A company called 3M developed it for the Centers for Medicare and Medicaid Services, and it replaces Volume 3 of the ICD-9-CM.

A

ICD-10-PCS

33
Q

A group called the ________ is responsible for annually updating the ICD-10-CM and ICD-10-PCS code sets.

A

Cooperating Parties

34
Q

List the Cooperating Parties

A
  1. American Hospital Association
  2. American Health Information Management Association
  3. Centers for Medicare and Medicaid Services
  4. National Center for Health Statistics
35
Q

The code set for identifying drugs in HIPAA transactions. The Food and Drug Administration, which is part of the Department of Health and Human Services, is responsible for updating the code set. HHS works with drug manufacturers to identify drugs and biologics (such as vaccines and insulin products).

A

National Drug Code (NDC)

36
Q

The code set you’d use to identify or describe health-related services that are not physician services, dentist services, or hospital surgical procedures. The codes include medical and surgical supplies, certain drugs, certain durable medical equipment, orthotic and prosthetic devices, and procedures and services that nonphysicians perform.

A

Healthcare Common Procedural Coding System, Level II (HCPCS)

37
Q

The combination of ________ is the standard code set for physician services and other healthcare services. The Centers for Medicare and Medicaid Services are responsible for updating the ________ code set.

A
  1. CPT and HCPCS Level II

2. HCPCS Level II

38
Q

HIPAA requires health plans to accept every valid code contained in an approved ________. Only those standards that are part of the national standard code sets can appear in a ________.

A
  1. Medical Code Set

2. HIPAA transaction

39
Q

Part of HIPAA’s transaction and code set rule require that covered entities have permanent ________.

A

Identification Numbers

40
Q

The Transaction Rule mandated four national healthcare identifiers:

A
  1. National Provider Identifier (NPI)
  2. National Health Plan Identifier (NHPI)
  3. National Employer Identifier for Healthcare
  4. National Health Identifier for Individuals
41
Q

Individual providers get NPIs, and we call those ________. Organizational providers also get NPIs, and we call those ________.

A
  1. Type 1 NPIs

2. Subpart or Type 2 NPIs

42
Q

The national identifier for health plans.

A

Health Plan Identifier (HPID)

43
Q

Organizations that don’t provide healthcare but interact with providers or health plans. These include atypical providers, such as companies that provide non-emergency transportation or assistance with daily living.

A

Other Entity Identifier (OEID)

44
Q

The IRS’s ________ was the logical choice to identify employers in health transactions.

A

Employer Identification Number (EIN)

45
Q

The original HIPAA law included an identifier for individuals. However, there has been widespread opposition to this. This is probably because its purposes and uses are unclear. As a result, there’s an indefinite delay in its implementation.

A

National Health Identifier for Individuals

46
Q

The Administrative Simplification Compliance Act amended HIPAA rules to require electronic transmission of all transactions submitted to Medicare, but ________ Medicare from responding to any transactions not sent electronically.

A

Prohibits

47
Q

The Department of Health and Human Services has adopted ________ code sets and made them the HIPAA standard.

A

Six

48
Q

By Oct. 1, 2014, the code sets will change to the ________. ________ will have to use ICD-10-CM as the designated diagnostic code set and ICD-10-PCS as the procedural code set. ________ are only required to use the ICD-10-CM at that time. They can continue to use the CPT and HCPCS Level II code sets for procedural coding.

A
  1. 10th edition of ICD
  2. Hospitals
  3. Physicians
49
Q

Why is it so important to have national provider and health plan identifiers?

A

Just like the HIPAA transactions, the identifiers help standardized information shared electronically. The standardized identifiers are also the response to frustration over various problems associated with the lack of a standard identifier, such as:

. Improper routing of transactions
. Rejected transactions due to insurance identification errors
. Difficulty in determining patient eligibility
. Challenges resulting from errors in identifying the correct health plan during claims processing.

50
Q

Does Health Level 7 only create HIPAA standards for claims attachments?

A

HL7 is a key player in the national movement toward electronic health records. HL7 creates standards for storing and transmitting lots of different types of data that would be included in a health record.

51
Q

What’s the problem with establishing a National Health Identifier for Individuals? What are people afraid might happen?

A

People within the healthcare community believe that increased threats to privacy will occur if all healthcare organizations use the same unique identifier. It can increase the threat to privacy by linking information about an individual throughout and across organizations. In addition, many Americans have protested implementation of a national identifier, believing that the identifier would give even more information to the federal government than the Social Security number already does.

52
Q

Have other countries established a national health identification number for each citizen? What have been the advantages and drawbacks?

A

Many countries require a national health identification number for citizens, with great success. However, other countries have privacy laws that differ greatly from ours, especially when it comes to health information privacy laws like HIPAA. Some countries have no privacy laws at all.

53
Q

Which of these is a provision of HIPAA’s Title II, Administrative Simplification?
. Group health plan requirements.
. Transactions, code sets, and identifiers.
. Health care portability and renewability.
. Revenue offsets.

A

Transactions, code sets, and identifiers

54
Q 
Let's say a provider is requesting coordination of benefits information from a health plan. What type of HIPAA transaction is this?
. 276 Health Care Claim Status Request.
. 837 Health Care Claim.
. 280 Health Plan Premium Payments.
. 270 Health Plan Eligibility Inquiry.
A

???? 270 Health Plan Eligibility Inquiry.

55
Q

Which HIPAA standard transaction has three types: Professional, Institutional, and Dental?
. 837 Health Care Claim.
. 278 Certification and Authorization of Referrals.
. 820 Health Plan Premium Payments.
. 270 Health Plan Eligibility Inquiry.

A

837 Health Care Claim

56
Q

Which is the required code set to identify or describe health-related services that aren’t physician services, dentist services, or hospital surgical procedures?
International Classification of Diseases, Tenth Revision, Clinical . Modification (ICD-10-CM).
. Health Care Common Procedure Coding System (HCPCS).
. Current Procedural Terminology (CPT).
. Code Dental Terminology (CDT).

A

Health Care Common Procedure Coding System (HCPCS)

57
Q

What national health care identifier is currently being ignored in HIPAA planning because so little is known about what it might be and how it might be used?
. National Provider Identifier.
. National Health Plan Identifier.
. National Health Identifier for Individuals.
. National Employer Identifier for Health Care.

A

National Identifier for Individuals.

Compliance (12 decks)

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