copyright ©2014 by saunders, an imprint of elsevier inc. all rights reserved 1 chapter 08 the...

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1

Chapter 08

The Electronic Claim

Insurance Handbook for the Medical Office

13th edition

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved

Electronic Claims Submission Overview

1. Define electronic data interchange.2. Summarize the advantages of electronic claim

submission.3. Describe the clearinghouse process that

follows after a claim is electronically received.4. Identify the transactions and code sets to use

for insurance claim transmission.5. State which insurance claim data elements

are required or situational for the 837P standard transaction format.

2

Lesson 8.1


Electronic Claims Submission Overview (cont’d)

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

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

8. Describe necessary components when adopting a practice management system.

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

3

Lesson 8.1


Electronic Data Interchange

Used for transmission of health insurance claims

Transmitted data is encrypted Improves efficiency of claims

submissions

4


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

5


Clearinghouses

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

6


Clearinghouses

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

7


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

8


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

9


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

10


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

11


Standard Unique Identifiers

Standard unique employer identifier Standard unique healthcare provider

identifier Standard unique health plan identifier Standard unique patient identifier

12


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

13


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

14


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

15


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

16


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

17


Encoder

Signature requirements Physician Patient

18


Clean Electronic Claims Submission

Claim scrubber software Encoder software Electronic clearinghouse Single and batch claims review

19


Privacy and Electronic Data

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

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

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

13. List the procedures for transmission of an electronic claim.

14. Explain the difference between carrier-direct and clearinghouse electronically transmitted insurance claims. 20

Lesson 8.2


Privacy and Electronic Data (Cont’d)

15. List computer transmission problems that can occur.

16. List HIPAA administrative safeguards for electronic protected health information.

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

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

19. Describe elements that should be considered when purchasing an in-office computer system. 21

Lesson 8.2


Interactive Transactions

Back-and-forth communication between two computer systems

Real time communication allows instant information transfer

22


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

23


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

24


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

25


Methods for Sending Claims

Cable modem Digital subscriber line (DSL) T-1 Direct data entry (DDE) Application service provider (ASP)

26


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

27


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

28


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)

29


Administrative Simplification Enforcement Tool

Online tool Assists healthcare providers, payers,

clearinghouses, and others to submit complaints regarding the HIPAA TCS rule

30


The Security Rule: Administrative, Physical, and

Technical Safeguards Administrative safeguards

Information access controls Internal audits Risk analysis and management Termination procedures

31


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

32


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)

33


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

34


Questions?

35

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