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Insurance Handbook for the Medical Office 13 th edition. Chapter 08 The Electronic Claim. Electronic Claims Submission Overview. Define electronic data interchange . Summarize the advantages of electronic claim submission.

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Insurance Handbook for the Medical Office

13th edition

Chapter 08

The Electronic Claim

electronic claims submission overview
Electronic Claims Submission Overview

Define electronic data interchange.

Summarize the advantages of electronic claim submission.

Describe the clearinghouse process that follows after a claim is electronically received.

Identify the transactions and code sets to use for insurance claim transmission.

State which insurance claim data elements are required or situational for the 837P standard transaction format.

Lesson 8.1

electronic claims submission overview cont d
Electronic Claims Submission Overview (cont’d)

Define a claim attachment, and explain when the electronic standards will be mandated.

Compare and contrast standard unique provider identifiers, health plan identifiers, and patient identifiers.

Describe necessary components when adopting a practice management system.

Describe the use of patient encounter forms and scannable encounter forms in electronic claim submission.

Lesson 8.1

electronic data interchange
Electronic Data Interchange
  • Used for transmission of health insurance claims
  • Transmitted data is encrypted
  • Improves efficiency of claims submissions
advantages of electronic claim submission
Advantages of Electronic Claim Submission
  • No signatures or stamps
  • No searching for an insurance carrier’s address
  • No postage costs or trips to post office
  • No need to store or file claim forms
  • Electronic claims leave an audit trail
  • Improved cash flow
  • Quicker processing time and payment
  • Reduced overhead and labor costs
  • Claims are checked electronically
    • Claims with missing/incorrect information are rejected
  • Rejected claims are sent back to the provider with a report
  • Batches of acceptable claims are sent to the appropriate payer
  • Corrected claims are reprocessed
  • Advantages of a clearinghouse
    • Translation of various formats to the HIPAA-compliant standard format
    • Reduction in time of claims preparation
    • Cost-effective method through loss prevention
    • Fewer claims rejections
    • Fewer delays in processing and quicker response time
    • More accurate coding with claims edits
    • Consistent reimbursement
transaction and code set regulations streamlining electronic data interchange
Transaction and Code Set Regulations: Streamlining Electronic Data Interchange
  • Benefits
    • More reliable and timely processing
    • Improved data accuracy
    • Easier and more efficient information access
    • Better tracking of transactions
    • Reduction of data entry/manual labor
    • Reduction of office expenses
transaction and code set standards
Transaction and Code Set Standards
  • HIPAA required code and data sets
    • ICD-10-CM/ICD-10-PCS codes
    • HCPCS codes
    • CDT codes
    • NDC codes
    • Taxonomy codes
    • Patient account number
    • Relationship to patient
    • Facility code value
    • Patient signature source code
electronic standard hipaa 837p
Electronic Standard HIPAA 837P
  • Electronic formats
    • Specialist authorization
    • Reimbursement claims
    • Request and respond to additional information
    • Healthcare claims/attachments/claims status
    • Coordination of benefits
    • Healthcare payment and remittance advice
    • Plan enrollment/disenrollment/eligibility
    • Premium payments
    • Referrals
    • First report of injury
    • Other transactions DHHS may prescribe by regulation
claims attachment standards
Claims Attachment Standards
  • Supplemental documents providing additional medical information
    • Certificate of Medical Necessity (CMNs)
    • Discharge summaries
    • Operative reports
  • Currently, PMS uses data field to indicate paper attachment
  • Electronic standards are going to be adopted
    • Regulation to be published in January 2014
    • Compliance by January 2016
standard unique identifiers
Standard Unique Identifiers
  • Standard unique employer identifier
  • Standard unique healthcare provider identifier
  • Standard unique health plan identifier
  • Standard unique patient identifier
practice management system
Practice Management System
  • Should be able to prepare, send, receive, and process HIPAA standard electronic transactions
  • Can help track receipt of Notice of Privacy Practices (NPP), patient treatment consents or authorization, and mapping disclosures
practice management system1
Practice Management System
  • Set security access to patient files in the software
  • Indicate date of receipt and signing of NPP
  • Insert date of patient’s authorization
  • Maintain files of practice’s authorization and notification forms
  • Track requests for amendments, restrictions on disclosure of PHI, and physician response to request
  • Track expiration dates
encounter or multipurpose billing forms
Encounter or Multipurpose Billing Forms
  • Also called charge slip, multipurpose billing form, patient service slip, routing form, superbill, transaction slip
  • Customized to meet the needs of the healthcare office
  • May include preprinted procedural or diagnostic codes
  • Scannable encounter forms save time
keying insurance data for claim transmission
Keying Insurance Data for Claim Transmission
  • DO: Use the patient account numbers to differentiate between patients with similar names
  • DO: Use correct numeric locations of service codes, current, valid CPT or HCPCS procedures codes
  • DO: Print an insurance billing worksheet or perform a front-end edit to look for and correct all errors before the claim is transmitted to the third-party payer
  • DO: Request electronic-error reports from the third-party payer to make corrections to the system
  • DO: Obtain and cross-check the electronic status report against all claims transmitted
keying insurance data for claim transmission1
Keying Insurance Data for Claim Transmission
  • DON’T: Use special characters
  • DON’T: Bill codes using modifiers -21 or -22 electronically unless the carrier receives documents to justify more payment
  • Signature requirements
    • Physician
    • Patient
clean electronic claims submission
Clean Electronic Claims Submission
  • Claim scrubber software
  • Encoder software
  • Electronic clearinghouse
  • Single and batch claims review
privacy and electronic data
Privacy and Electronic Data

Name some methods of interactive computer transactions for transmitting insurance claims.

Relate the electronic funds transfer process and mandated requirements under the Affordable Care Act (ACA).

Identify the ASC X12 Health Care Claim Payment/Advice (835).

List the procedures for transmission of an electronic claim.

Explain the difference between carrier-direct and clearinghouse electronically transmitted insurance claims.

Lesson 8.2

privacy and electronic data cont d
Privacy and Electronic Data (Cont’d)

List computer transmission problems that can occur.

List HIPAA administrative safeguards for electronic protected health information.

State technical and physical safeguards used to secure privacy of e-mail, Internet, and instant messaging.

Explain handling of data storage and data disposal for good electronic records management.

Describe elements that should be considered when purchasing an in-office computer system.

Lesson 8.2

interactive transactions
Interactive Transactions
  • Back-and-forth communication between two computer systems
  • Real time communication allows instant information transfer
electronic funds transfer
Electronic Funds Transfer
  • Electronic funds transfer (EFT) can speed up reimbursement
  • Federal government has established a uniform procedure
    • Part of HIPAA Administrative Simplification
    • Health care providers must comply by January 2014
electronic remittance advice
Electronic Remittance Advice
  • Online transaction about the status of a claim
  • Medicare ERA
    • Formerly called Medicare explanation of benefits (EOMB or EOB)
    • Based on American National Standards Institute (ANSI) Accredited Standards Committee X12 (ASC X12) Health Care Claim Payment/Advice (835) or ANSI 835
driving the data
Driving the Data
  • Set up the database
  • Enter data
  • Batch or compile a group of claims
  • Connect the computerized database with the clearinghouse or direct to the payer
  • Transmit the claims
  • Review the clearinghouse reports
methods for sending claims
Methods for Sending Claims
  • Cable modem
  • Digital subscriber line (DSL)
  • T-1
  • Direct data entry (DDE)
  • Application service provider (ASP)
computer claims systems
Computer Claims Systems
  • Carrier-direct
    • The medical practice has its own computer and software to process claims
    • The insurer sometimes leases a dedicated terminal to the physician
  • Clearinghouse
    • The physician’s office sends paper claims or a disk or tape to the clearinghouse, which forwards a batch of claims to the insurer
transmission reports
Transmission Reports
  • Send and receive file reports
  • Batch claim report billed summary
  • Scrubber report
  • Transaction transmission summary
  • Rejection analysis report
  • Electronic inquiry or claims status review
electronic processing problems
Electronic Processing Problems
  • Upgrade to ASC X12 Version 5010 results in these common errors:
    • Billing provider address
    • Zip code
    • Anesthesia minutes
    • Primary identification code qualifiers
    • Billing provider NPI number
    • National Drug Code (NDC)
administrative simplification enforcement tool
Administrative Simplification Enforcement Tool
  • Online tool
  • Assists healthcare providers, payers, clearinghouses, and others to submit complaints regarding the HIPAA TCS rule
the security rule administrative physical and technical safeguards
The Security Rule: Administrative, Physical, and Technical Safeguards
  • Administrative safeguards
    • Information access controls
    • Internal audits
    • Risk analysis and management
    • Termination procedures
the security rule administrative physical and technical safeguards1
The Security Rule: Administrative, Physical, and Technical Safeguards
  • Technical safeguards
    • Access controls
    • Audit controls
    • Automatic log-offs
    • Use of passwords
  • Physical safeguards
    • Media and equipment controls
    • Physical access controls
    • Secure workstation
records management
Records Management
  • Data storage: back up data frequently
  • Data disposal: data must be complete eliminated
  • Electronic power protection: surge suppressors or uninterruptible power supply (UPS)
selection of an office computer system
Selection of an Office Computer System
  • Cost of basic equipment—purchase or lease?
  • Accessories
  • Space requirements
  • Electrical/transmission lines
  • Separate fax and modem lines?
  • Costs of electricity
  • Telephone lines
  • Maintenance
  • Software