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Learning Objectives
Learning Objectives
zzSummarize advantages of electronic claim submission.Summarize advantages of electronic claim submission.
z
zIdentify the transactions and code sets to use for insurance claIdentify the transactions and code sets to use for insurance claims transmission.ims transmission. z
zState which insurance claim data elements are required or situatState which insurance claim data elements are required or situational for the 837P standard ional for the 837P standard
transaction format.
transaction format. z
zDescribe necessary components when adopting a practice managemenDescribe necessary components when adopting a practice management system.t system.
z
zDescribe the use of patient encounter forms and Describe the use of patient encounter forms and scannablescannableencounter forms in electronic encounter forms in electronic
claim submission.
claim submission. z
zName some methods of interactive computer transactions for transName some methods of interactive computer transactions for transmitting insurance claims.mitting insurance claims.
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Learning Objectives (cont
Learning Objectives (cont
’
’
d.)
d.)
zzList computer transmission problems that can occur.List computer transmission problems that can occur.
z
zExplain the difference between carrierExplain the difference between carrier--direct and clearinghouse electronically transmitted direct and clearinghouse electronically transmitted insurance claims.
insurance claims. z
zState measures used to secure privacy of electronic mail, InternState measures used to secure privacy of electronic mail, Internet, and instant messaging.et, and instant messaging.
z
zList HIPAA administrative safeguards for electronic protected heList HIPAA administrative safeguards for electronic protected health information.alth information.
z
zExplain the handling of data storage and data disposal for good Explain the handling of data storage and data disposal for good electronic records electronic records management.
management.
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Electronic Data Interchange (EDI)
Electronic Data Interchange (EDI)
zzUsed for transmission of health insurance claimsUsed for transmission of health insurance claims
z
zTransmitted data is encryptedTransmitted data is encrypted
z
zImproves efficiency of claims submissionsImproves efficiency of claims submissions
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Advantages of Electronic Claim Submission
Advantages of Electronic Claim Submission
zzNo signatures or stampsNo signatures or stamps
z
zNo searching for an insurance carrierNo searching for an insurance carrier’’s addresss address z
zNo postage costs or trips to post officeNo postage costs or trips to post office
z
zNo need to store or file claim formsNo need to store or file claim forms
z
zElectronic claims leave an audit trailElectronic claims leave an audit trail
z
zImproved cash flowImproved cash flow
z
zQuicker processing time and paymentQuicker processing time and payment
z
zReduced overhead and labor costsReduced overhead and labor costs
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Clearinghouses
Clearinghouses
zzClaims are checked electronicallyClaims are checked electronically
¾
¾Claims with missing/incorrect information are rejectedClaims with missing/incorrect information are rejected z
zRejected claims are sent back to the provider with a reportRejected claims are sent back to the provider with a report
z
zBatches of acceptable claims are sent to the appropriate payerBatches of acceptable claims are sent to the appropriate payer
z
zCorrected claims are reprocessedCorrected claims are reprocessed
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Advantages of a Clearinghouse
Advantages of a Clearinghouse
zzTranslation of various formats to the HIPAATranslation of various formats to the HIPAA--compliant standard formatcompliant standard format z
zReduction in time of claims preparationReduction in time of claims preparation
z
zCostCost--effective method through loss preventioneffective method through loss prevention
z
z
zFewer delays in processing and quicker response timeFewer delays in processing and quicker response time
z
zMore accurate coding with claims editsMore accurate coding with claims edits
z
zConsistent reimbursementConsistent reimbursement
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HIPAA Transaction and Code Set (TCS) Benefits
HIPAA Transaction and Code Set (TCS) Benefits
zzMore reliable and timely processingMore reliable and timely processing
z
zImproved data accuracyImproved data accuracy
z
zEasier and more efficient information accessEasier and more efficient information access
z
zBetter tracking of transactionsBetter tracking of transactions
z
zReduction of data entry/manual laborReduction of data entry/manual labor
z
zReduction of office expensesReduction of office expenses
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HIPAA Required Code and Data Sets
HIPAA Required Code and Data Sets
zzICDICD--99--CM codesCM codes
z zCPTCPT--4 codes4 codes z zCDT codesCDT codes z zNDC codesNDC codes z
zICDICD--1010--CM/ICDCM/ICD--1010--PCS codesPCS codes
z
zTaxonomy codesTaxonomy codes
z
zPatient account numberPatient account number
z
zRelationship to patientRelationship to patient
z
zFacility code valueFacility code value
z
zPatient signature source codePatient signature source code
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Electronic Formats
Electronic Formats
zzSpecialist authorizationSpecialist authorization
z
zReimbursement claimsReimbursement claims
z
zRequest and respond to additional informationRequest and respond to additional information
z
zHealthcare claims/attachments/claims statusHealthcare claims/attachments/claims status
z
zCoordination of benefitsCoordination of benefits
z
zHealthcare payment and remittance adviceHealthcare payment and remittance advice
z
zPlan enrollment/Plan enrollment/disenrollmentdisenrollment/eligibility/eligibility
z
zPremium paymentsPremium payments
z
zReferralsReferrals
z
zFirst report of injuryFirst report of injury
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Standard Unique Identifiers
Standard Unique Identifiers
zzStandard unique employer identifierStandard unique employer identifier
z
zStandard unique healthcare provider identifierStandard unique healthcare provider identifier
z
zStandard unique health plan identifierStandard unique health plan identifier
z
zStandard unique patient identifierStandard unique patient identifier
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Practice Management System
Practice Management System
zzShould be able to prepare, send, receive, and process HIPAA stanShould be able to prepare, send, receive, and process HIPAA standard electronic dard electronic transactions
transactions z
zCan help track receipt of Notice of Privacy Practices (NPP), patCan help track receipt of Notice of Privacy Practices (NPP), patient treatment consents or ient treatment consents or authorization, and mapping disclosures
authorization, and mapping disclosures
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HIPAA
HIPAA
-
-
Ready PMS
Ready PMS
zz
zIndicate date of receipt and signing of NPPIndicate date of receipt and signing of NPP
z
zInsert date of patientInsert date of patient’’s authorizations authorization
z
zMaintain files of practiceMaintain files of practice’’s authorization and notification formss authorization and notification forms
z
zTrack requests for amendments, restrictions on disclosure of PHITrack requests for amendments, restrictions on disclosure of PHI, and physician response to , and physician response to request
request z
zTrack expiration datesTrack expiration dates
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Encounter or Multipurpose Billing Forms
Encounter or Multipurpose Billing Forms
zzAlso called charge slip, multipurpose billing form, patient servAlso called charge slip, multipurpose billing form, patient service slip, routing form, ice slip, routing form, superbillsuperbill, ,
transaction slip
transaction slip z
zCustomized to meet the needs of the healthcare officeCustomized to meet the needs of the healthcare office
z
zMay include preprinted procedural or diagnostic codesMay include preprinted procedural or diagnostic codes
z
zScannableScannableencounter forms save timeencounter forms save time
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Do
Do
’
’
s and
s and
Dont
Dont
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’
s
s
for Keying Insurance Data for Claims Submission
for Keying Insurance Data for Claims Submission
DO: Use the patient account numbers to differentiate between pat
DO: Use the patient account numbers to differentiate between patients with similar names.ients with similar names. DO: Use correct numeric locations of service codes, current, val
DO: Use correct numeric locations of service codes, current, valid CPT or HCPCS procedures codes.id CPT or HCPCS procedures codes. DO: Print an insurance billing worksheet or perform a front
DO: Print an insurance billing worksheet or perform a front--end edit to look for and correct all errors before the claim is end edit to look for and correct all errors before the claim is transmitted to transmitted to the third
the third--party payer.party payer. DO: Request electronic
DO: Request electronic--error reports from the thirderror reports from the third--party payer to make corrections to the system.party payer to make corrections to the system. DO: Obtain and cross
DO: Obtain and cross--check the electronic status report against all claims transmittecheck the electronic status report against all claims transmitted.d. DON
DON’’T: Use special characters.T: Use special characters. DON
DON’’T: Bill codes using modifiers T: Bill codes using modifiers --21 or 21 or --22 electronically unless the carrier receives documents to justi22 electronically unless the carrier receives documents to justify more payment.fy more payment.
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Encoder
Encoder
zzSignature requirementsSignature requirements
¾
¾PhysicianPhysician ¾
¾PatientPatient
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Clean Electronic Claims Submission
Clean Electronic Claims Submission
zzClaim scrubber softwareClaim scrubber software
z
zEncoder softwareEncoder software
z
zElectronic clearinghouseElectronic clearinghouse
z
zSingle and batch claims reviewSingle and batch claims review
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Interactive Transactions
Interactive Transactions
zzBackBack--andand--forth communication between two computer systemsforth communication between two computer systems z
zReal time communication allows instant information transferReal time communication allows instant information transfer
z
zElectronic funds transfer (EFT) can speed up reimbursementElectronic funds transfer (EFT) can speed up reimbursement
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Electronic Remittance Advice (ERA)
Electronic Remittance Advice (ERA)
zzERA: Online transaction about the status of a claimERA: Online transaction about the status of a claim
z
zMedicare ERAMedicare ERA
¾
¾formerly called Medicare explanation of benefits (EOMB or EOB)formerly called Medicare explanation of benefits (EOMB or EOB) ¾
¾based on American National Standards Institute (ANSI) Accreditedbased on American National Standards Institute (ANSI) AccreditedStandards Committee X12 (ASC X12) Standards Committee X12 (ASC X12) Health Care Claim Payment/Advice (835) or ANSI 835
Health Care Claim Payment/Advice (835) or ANSI 835
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Procedures for Claim Transmission
Procedures for Claim Transmission
zzSet up the database.Set up the database.
z
zEnter data.Enter data.
z
z
zConnect the computerized database with the clearinghouse or direConnect the computerized database with the clearinghouse or direct to the payer.ct to the payer. z
zTransmit the claims.Transmit the claims.
z
zReview the clearinghouse reports.Review the clearinghouse reports.
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Methods for Sending Claims
Methods for Sending Claims
zzCable modemCable modem
z
zDigital subscriber line (DSL)Digital subscriber line (DSL)
z
zTT--11
z
zDirect data entry (DDE)Direct data entry (DDE)
z
zApplication service provider (ASP)Application service provider (ASP)
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Computer Claims Systems
Computer Claims Systems
zzCarrierCarrier--directdirect
¾
¾The medical practice has its own computer and software to procesThe medical practice has its own computer and software to process claims. s claims. ¾
¾The insurer sometimes leases a dedicated terminal to the physiciThe insurer sometimes leases a dedicated terminal to the physician.an.
z
zClearinghouseClearinghouse
¾
¾The physicianThe physician’’s office sends paper claims or a disk or tape to the clearinghous office sends paper claims or a disk or tape to the clearinghouse, which forwards a batch se, which forwards a batch of claims to the insurer.
of claims to the insurer.
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Transmission Reports
Transmission Reports
zzSend and receive file reportsSend and receive file reports
z
zScrubber reportScrubber report
z
zTransaction transmission summaryTransaction transmission summary
z
zRejection analysis reportRejection analysis report
z
zElectronic inquiry or claims status reviewElectronic inquiry or claims status review
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Administrative Simplification Enforcement Tool (ASET)
Administrative Simplification Enforcement Tool (ASET)
zzOnline toolOnline tool
z
zAssists healthcare providers, payers, clearinghouses, and othersAssists healthcare providers, payers, clearinghouses, and othersto submit complaints to submit complaints
regarding the HIPAA TCS rule
regarding the HIPAA TCS rule
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The Security Rule: Administrative, Physical, and Technical
The Security Rule: Administrative, Physical, and Technical
Safeguards
Safeguards
zzAdministrative safeguardsAdministrative safeguards
¾
¾information access controlsinformation access controls ¾
¾internal auditsinternal audits ¾
¾risk analysis and managementrisk analysis and management ¾
¾termination procedurestermination procedures z
zTechnical safeguardsTechnical safeguards
¾
¾access controlsaccess controls ¾
¾audit controlsaudit controls ¾
¾automatic logautomatic log--offsoffs ¾
¾use of passwordsuse of passwords
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The Security Rule (cont
The Security Rule (cont
’
’
d.)
d.)
zzPhysical safeguardsPhysical safeguards
¾
¾media and equipment controlsmedia and equipment controls ¾
¾physical access controlsphysical access controls ¾
¾secure workstationsecure workstation
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Computer Security Prevention Measures
Computer Security Prevention Measures
z
z
z Never leave disks or tapes unguardedNever leave disks or tapes unguarded z
z Use a privacy filter on the computer monitorUse a privacy filter on the computer monitor z
z Log off computer before leaving work stationLog off computer before leaving work station z
z DoubleDouble--check credentials of all consultantscheck credentials of all consultants
z
z Read equipment manuals, especially Read equipment manuals, especially ““Security ControlsSecurity Controls””information, and follow all directionsinformation, and follow all directions z
z Store confidential data on diskettes or Store confidential data on diskettes or ““zipzip””disks, not the hard drivedisks, not the hard drive
z
z Store all diskettes in a locked, secure locationStore all diskettes in a locked, secure location z
z Use firewall and antivirus softwareUse firewall and antivirus software z
z Develop passwords for all computer usersDevelop passwords for all computer users z
z Use only account numbers in eUse only account numbers in e--mailmail
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Records Management
Records Management
zzData storage: back up data frequentlyData storage: back up data frequently
z
zElectronic power protection: surge suppressors or uninterruptiblElectronic power protection: surge suppressors or uninterruptible power supply (UPS)e power supply (UPS)
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Selection of an
Selection of an
Office Computer System
Office Computer System
z
zCost of basic equipmentCost of basic equipment——purchase or lease?purchase or lease?
z
zAccessoriesAccessories
z
zSpace requirementsSpace requirements
z
zElectrical/transmission linesElectrical/transmission lines
z
zSeparate fax and modem lines?Separate fax and modem lines?
z
zCosts of electricityCosts of electricity
z
zTelephone linesTelephone lines
z
zMaintenanceMaintenance
z
