Explain Reimbursement Claims Processing and Support Processes Flashcards
What is a clearinghouse?
Company that sorts, translates, and cleans packages of claims to be sent to the insurance company.
What is the process of reimbursement claims processing?
- Provider completes visit
-Medical coder assesses patient’s chart and translates information into medical code (may involve HCPCS code for item patient received or a CPT code which is what an office visit uses)
-Coder assigns ICD-10-CM codes for diagnoses provider uses,
-Information is entered into CMS-1500 for outpatient visits (Which has been translated electronically as an EDI 837 professional file)
-EDI 837 professional file goes in batch of claim submissions to the clearinghouse.
-Clearinghouse ensures claim is ready to be sent to insurance company. (If it isnt it is sent back to provider’s office for corrections)
-Insurance company sorts claim into proper department for adjudication.
-Patient’s benefits are evaluated against claim to see if they’ll have coverage for that procedure.
-Medical necessity is established.
-Automation (aka the computer) is programmed with the necessary diagnoses and benefits into the adjudication system to be processed and paid for by computer.
-Payment is issued to provider via Electronic Funds Transfer (EFT) or paper check.
-Provider receives an EDI 835 electronic remittance advice (ERA) through the clearinghouse, which explains why and how the claim was paid the way it was.
What does a ‘clean’ claim mean?
No errors and have not been rejected by clearinghouse, and has been sent to the insurance company within 90 days.
What do all insurance companies require of a clean claim?
That it be submitted within a certain time period.
What is informed and written consent?
The patient signing a document to consent to a procedure done by a physician after being known of risks and benefits of such procedure.
What is implied consent?
Non-verbal actions such as showing up to an appointment, holding out an arm for a shot, and other similar actions.
When is an Assignment of Benefits (AoB) used?
To ask the insurance company to pay the provider directly instead of patient for services due to a health savings plan or flexible spending account and high deductible health plan (which most likely they’ll have a health savings account).
When is an Advanced Beneficiary Notice (ABD) used?
For medicare and medicaid patients, if a service isn’t covered, the patient must sign an ABN. (it lists what is and isn’t covered by the insurance).
Patient must be informed through written word of the cost, reason provider thinks they should have the service, and why medicare and medicaid wont cover it. (MUST BE PROVIDED BEFORE SERVICE IS RENDERED).
Within EHR, all outstanding accounts will be listed in _______________?
An Aged Receivable report (also known as an A/R report, or A/R).
What is included in the A/R report?
Patient names, how much money is outstanding for each patient, and whether the outstanding balance is for the insurance or the patient. (It is divided into how many days outstanding, 0-30, 30-60, 60-90, 90-120, and over 120 days).
What is the time frame that insurance usually pays?
Within 30-45 days.
When is a National Correct Coding Initiative Edits (NCCI edits)?
Such as one procedure already has compensation for the second one). Ex: code for closure of wound in surgical procedures.
What do some codes have that simply means they can’t be billed together?
Medically Unlikely Edits (MUE).
How does the order of codes go?
First listed diagnosis in an outpatient setting should be reason as to why they came, in inpatient it should be the principle diagnoses should they need to be admitted to hospital.
In reference to procedure codes, the Higher weighted procedure is listed first followed by other procedure codes with modifiers attached. (modifiers help lower rate)
What is the CMS-1500 (also known as the UCF-1500)?
PROFESSIONAL CLAIM FORM: Physician office services and procedures in office.
Centers for medicare and medicaid services’ professional, universal health claim form.
Used by providers of outpatient health services to bill their fees to health carriers (or third-party payers) and is sometimes referred to as the AMA (American Medical Association) form.
