CPB CHAPTER 9 STUDY GUIDE Questions & Answers

FEE SCHEDULE - ANSWERSA LIST OF FEES PHYSICIANS ESTABLISH AS THE FAIR PRICE FOR THE SERVICES THEY PROVIDE. DATA ENTRY - ANSWERSUSED FOR: DEMOGRAPHIC INFORMATION, CPT, HCPCS LEVEL II, AND ICD - 10 - CM CODES TO REPORT THE SERVICES FOR THAT ENCOUNTER, PAYMENTS AND ADJUSTMENTS FROM INSURANCE CARRIERS (REDUCE PAYMENT DELAY) VERIFY INSURANCE - ANSWERSONE OF THE BEST WAYS TO AVOID PAYMENT DELAY IS TO DO THIS (REDUCE PAYMENT DELAY) SUBMIT CLEAN CLAIMS - ANSWERSA CLAIM WITH ALL OF THE INFORMATION REQUIRED TO BE PROCESSED. (REDUCE PAYMENT DELAY) SUBMIT CLAIMS ELECTRONICALLY - ANSWERSREDUCES CLERICAL PAPERWORK, COST OF POSTAGE, ENVELOPES, AND FORMS. SUPPLIES THE PRACTICE WITH REPORTS INDICATING CLAIMS WERE RECEIVED, AND EITHER ACCEPTED OR REJECTED. (REDUCE PAYMENT DELAY) CHECK STATUS REPORTS - ANSWERSARE REPORTS SENT FROM THE PAYERS IDENTIFYING THE STATUS OF THE CLAIMS THAT WERE RECEIVED. THE REPORT WILL IDENTIFY EACH CLAIM WITH THE PATIENTS' NAMES AND DATE(S) OF SERVICE AND WHETHER THE CLAIMS WERE ACCEPTED OR REJECTED BY THE PAYER. (REDUCE PAYMENT DELAY) POST CONTRACTUAL ADJUSTMENTS - ANSWERSA CONTRACTUAL ADJUSTMENT IS THE AMOUNT THE PROVIDER AGREES TO ACCEPT AS A PARTICIPATING PROVIDER WITH THE INSURANCE CARRIER. PRIOR AUTHORIZATION - ANSWERSA REQUIREMENT THAT A PHYSICIAN OBTAINS APPROVAL FROM A HEALTH PLAN TO PERFORM A SPECIFIC SERVICE/PROCEDURE OR PRESCRIBE A SPECIFIC MEDICATION. WITHOUT THIS PRIOR APPROVAL, THE HEALTH PLAN MAY NOT PROVIDE COVERAGE, OR PAY FOR THE SERVICE/PROCEDURE OR MEDICATION. CLAIM SCRUBBERS - ANSWERSA SOFTWARE PROGRAM THAT REVIEWS CLAIMS FOR KEY COMPONENTS BEFORE THE CLAIMS ARE SENT TO AN INSURANCE COMPANY. WILL IDENTIFY POSSIBLE ERRORS BEFORE THE CLAIM IS SUBMITTED. ACCOUNTS RECEIVABLE OR A/R - ANSWERSMONEY OWED TO THE PRACTICE FOR SERVICES RENDERED AND BILLED. PAYMENTS DUE FROM PATIENTS, PAYERS, OR OTHER GUARANTORS DAILY DEPOSITS - ANSWERSWHEN PATIENTS ARE SEEN IN THE OFFICE, COPAYMENTS, DEDUCTIBLES, COINSURANCE, OR PATIENT BALANCES MAY BE COLLECTED BY THE OFFICE STAFF. PATIENT PAYMENTS WILL ALSO COME INTO THE OFFICE BY MAIL, ALONG WITH PAYMENTS FROM INSURANCE COMPANIES WHERE DIRECT DEPOSIT IS NOT AN OPTION. DIRECT DEPOSITS - ANSWERSMANY OF THE INSURANCE PAYERS WILL PAY CLAIMS WITH DIRECT DEPOSIT. ONCE THE ADJUDICATION PROCESS HAS BEEN FINALIZED, THE PAYER WILL SEND THE REMITTANCE ADVICE (RA) TO THE PROVIDER AND AN EXPLANATION OF BENEFITS (EOB) TO THE PATIENT. ELECTRONIC CLAIMS - ANSWERSCAN BE SUBMITTED TO A CARRIER FROM A PROVIDER'S OFFICE USING A COMPUTER WITH SOFTWARE THAT MEETS ELECTRONIC FILING REQUIREMENTS AS ESTABLISHED BY HIPAA CLAIM STANDARDS. DSL (DIGITAL SUBSCRIBER LINE) - ANSWERSA VERY HIGH SPEED CONNECTION THAT USES THE SAME WIRES AS A REGULAR TELEPHONE LINE. PROVIDERS INSTALL SOFTWARE ON THEIR COMPUTER TO USE A DSL SERVICE. EXTRANET - ANSWERSA PRIVATE COMPUTER NETWORK ALLOWING CONTROLLED ACCESS TO THE PAYER'S SYSTEM. THE PROVIDER HAS LIMITED ACCESS TO PAYER AND PATIENT DATA ELEMENTS ON THEIR PATIENTS ONLY. INTERNET - ANSWERSA VAST COMPUTER NETWORK LINKING SMALLER COMPUTER NETWORKS WORLDWIDE. USING THE INTERNET ALLOWS PROVIDERS SECURE TRANSMISSION OF CLAIMS WITHOUT THE NEED FOR ADDITIONAL SOFTWARE. MAGNETIC TAPE, DISK, OR COMPACT DISC MEDIA - ANSWERSMAGNETIC TAPE, DISK, OR COMPACT DISC MEDIA CAN BE USED TO MANUALLY MOVE OR TRANSMIT INFORMATION. FOR EXAMPLE, DOWNLOAD THE INOFRMATION ONTO A COMPUTER DISC MEDIA AND THEN THIS DISC WOULD BE MAILED TO THE PAYER. CLEARINGHOUSE REPORT - ANSWERSAN ENTITY THAT PROCESSES OR FACILITATES THE PROCESSING OF CLAIMS FOR PROVIDERS AND HEALTHCARE PLANS. HOW DOES A CLEARINGHOUSE WORK? - ANSWERSA CLAIM OR A BATCH OF CLAIMS ARE SUBMITTED ELECTRONICALLY TO THE CLEARINGHOUSE. TYPICALLY, WITHIN 24 HOURS THE CLEARINGHOUSE WILL SEND A REPORT TO THE PROVIDER. THIS REPORT WILL IDENTIFY ALL CLAIMS SENT AND ALSO ALL REJECTED CLAIMS. TIMELY FILING - ANSWERSTHE DEADLINE FOR SUBMITTING A CLEAN CLAIM TO AN INSURANCE PAYER. EACH PAYER HAS THEIR OWN TIMELY FILING LIMITS. AUDITS - ANSWERSA REVIEW AND EVALUATION OF HEALTHCARE PROCEDURES AND DOCUMENTATION FOR THE PURPOSE OF COMPARING THE QUALITY OF SERVICES OR PRODUCTS PROVIDED IN A GIVEN SITUATION. CHARGEMASTER - ANSWERSA MASTER PRICE LIST OF ALL SERVICES, SUPPLIES, DEVICES, AND MEDICATIONS CHARGED FOR INPATIENT OR OUTPATIENT SERVICES BY A HEALTHCARE FACILITY. LCD (LOCAL COVERAGE DETERMINATION) - ANSWERSWHEN A CONTRACTOR MAKES A RULING AS TO WHETHER A SERVICE OR ITEM CAN BE REIMBURSED NCD (NATIONAL COVERAGE DETERMINATION) - ANSWERSSPECIFY THE MEDICARE COVERAGE OF SPECIFIC SERVICES ON A NATIONAL LEVEL. SUBROGATION - ANSWERSWHEN AN INSURANCE COMPANY ATTEMPTS TO RECOUP EXPENSES FOR A PAID CLAIM WHEN ANOTHER PAYER SHOULD HAVE BEEN RESPONSIBLE.