Healthcare Claim Preparation and Transmission

These flashcards cover key vocabulary and definitions related to healthcare claims preparation and transmission.

CMS-1500

The current paper claim form approved by the NUCC for reporting physician services.

HIPAA 837P

An electronic form used to send a claim for payment for physician services.

Carrier Block

Data entry area in the upper right portion of CMS-1500 for payer's address.

Rendering Provider

Healthcare professional who provides health services reported on a claim.

Billing Provider

Person or organization sending a HIPAA claim; also may provide services.

Pay-to Provider

Entity that will receive payment for services on a claim.

Referring Provider

Provider who refers a patient for specific healthcare services.

Clean Claim

Claim accepted by a health plan for adjudication.

EDI

Electronic Data Interchange; a method for transmitting claim data electronically.

NUCC

National Uniform Claim Committee, responsible for claim content.

Data Element

Smallest unit of information in a HIPAA transaction, like a name or address.

Required Data Element

Information that must be supplied on an electronic claim.

Situational Data Element

Information that must be on a claim in conjunction with certain other data elements.

Claim Attachments

Additional documents submitted with a claim that provide further information.

Claim Information

Data about the services provided on a claim, including coding and charges.

Service Line Information

Details related to each service provided on a claim, including charges.

Clearinghouse

A third-party entity that processes claims from providers to payers.

DDE

Direct Data Entry; a method for entering claims directly via an online service.

Hierarchy of Data Elements

The structured order of data elements in a HIPAA 837P claim transactions.

Payer Information

Data regarding the insurance coverage and details about the payer.

Subscriber Information

Information about the individual insured under a health policy.

Procedure Codes

Codes used to represent medical services and procedures provided.

Billing Provider Information

Contact details of the entity submitting the claim for payment.

Patient Information Section

Part of the CMS-1500 form that captures essential details about the patient.

Signature of Physician

Required acknowledgment by the physician certifying the accuracy of the claim.

Electronic Funds Transfer

The electronic process of transferring money to settle claims.

Remittance Advice

Documentation sent by a payer explaining payment details for a claim.

Explanation of Benefits (EOB)

A statement detailing what services were paid or denied by the insurer.

Major Methods of Transmission

Three ways to send claims: directly, via clearinghouse, or using DDE.

ICD-10 Codes

International Classification of Diseases, 10th Revision; coding system for diseases.

Adjudication

The process of settling a claim by the insurer.

Financial Responsibility

Determination of who is liable for the costs of healthcare services.

Patient DOB

Date of birth of the patient, a critical data point on health claims.

Insurance Plan Name

The name of the health insurance policy under which a patient is covered.

Facility Information

Details about where the patient received healthcare services.