MED 134 ch 10

Once the List Only… filters have been applied, only the claims that match the criteria are listed at the__________of the main Claim Management dialog box.
bottom
The insurance claim is the most important document for ______.
correct reimbursement from payers
In Medisoft Network Professional, the date that a claim was created is entered in ____________ format.
MMDDCCYY
In Medisoft Network Professional, an attachment control number is required if the transmission code is __________.
Other than AA
In Medisoft Network Professional, the __________provider is the patient’s regular physician.
assigned
A(n)________________review checks for bundled codes, among other things.
automated
A filter is defined as a condition that data must meet to be
selected
_________________is a method of claim transmission in which a member of the provider’s billing staff manually enters claims into an application on the payer’s website.
Direct data entry (DDE)
The “official” name for the HIPAA standard transaction for electronic claims is the
HIPAA X12 837 Health Care Claim
____________ provide further detail for claim status category codes.
claim status codes
When a claim is active in Medisoft Network Professional’s Claim Management dialog box, it can be edited by
clicking the Edit button
double-clicking on the claim itself
Multiple indicators in the Case Indicator box of Medisoft Network Professional’s Create Claims dialog box must be separated by __________.
commas
During the payer’s adjudication process, if the automated review finds problems, the claim is ____________ and set aside for development.
suspended
A claims examiner contacts the office regarding the place of service for a particular claim. The claim is likely to be in the _____________ step of the adjudication process.
manual review
Insurance claims are ____________ for payment within the Claim Management area of Medisoft Network Professional.
created
edited
submitted
Before claims are sent, Medisoft Network Professional performs edits, including
ANSI edits
user-defined edits
common edits
The HIPAA claim can capture over ______data elements.
1,000
The Last Claim button in Medisoft Network Professional’s Claim Management dialog box
makes the last claim in the list active
A printout of a paper claim is easy to read; a printout of a HIPAA claim___________.
cannot easily be read because it prints out in a computer format that removes blank spaces
If a particular payer states in the participation contract that it will pay claims on the twenty-fifth day, for what date would the biller set the PM/EHR to automatically issue a HIPAA 276 for unpaid claims?
the twenty-sixth day, the first date that the payment is overdue
To run the various edits that are possible in Medisoft Network Professional before transmitting electronic claims, click ________________after selecting Claims on the Process menu.
Check Claims
The ________________________ of the payer checks for medical necessity.
medical review program
In Medisoft Network Professional, a report ________code is a two-digit code that indicates how a report is being sent to the ________.
transmission; payer
________________buttonssimplify the task of moving from one entry to another.
Navigator
To transmit electronic claims, the practice must establish _______with clearinghouses and payers.
accounts
The ____________ tab(s) in Medisoft Network Professional’s Claim dialog box display(s) information about claims being submitted to a patient’s non primary insurance carriers.
Carrier 1 and Carrier 2
Medisoft Network Professional claims can be selected and viewed by
insurance carrier
batch number
chart number
What boxes are located in the EDI Report section in Medisoft Network Professional?
Report Type Code
Attachment Control Number
Report Transmission Code
The time period in which a health plan is obligated to process a claim
claim turnaround time
Claims that are billed to Medicare and then submitted to Medicaid
crossover claims
The process followed by health plans to examine claims and determine benefits
adjudication
A condition that data must meet to be selected
filter
The rules that specify the number of days after the date of service that the practice has to file the claim
timely filing
A payer’s decision about the benefits due for a claim
determination
Claim status during adjudication when the payer is waiting for information from the submitter
pending
The smallest units of information in a HIPAA transaction, such as a person’s name
data elements
Classification of accounts receivable by the length of time an account is due
aging
The term is used by payers to indicate that more information is needed for claim
development
(T/F) In Medisoft Network Professional, filters are applied in the Claim Management dialog box.
False
– filters are applied in the List Only Claims That Match dialog box
(T/F) When an attachment must accompany a claim filed electronically, specific information must be entered in the Diagnosis tab of the Case folder in Medisoft Network Professional.
True
(T/F) Insurance claims are created from within the Revenue Management area of Medisoft Network Professional.
False
– they are created within the Claim Management area
(T/F) For each service line on a claim, the payer makes a payment adjudication—a decision whether to (1) pay it, (2) deny it, (3) hold it for further processing, or (4) pay it at a reduced level.
False
– the payer makes a payment determination
(T/F) The HIPAA X12 276/277 Health Care Claim Status Inquiry/ Response is the standard electronic transaction to obtain the current status of a claim during the adjudication process.
True
(T/F) The HIPAA standard transaction for electronic claims is the HIPAA X12 837 Health Care Claim, usually called the HIPAA claim.
True
(T/F) The HIPAA 277 transaction from the payer uses claim status category codes for the main types of responses.
True
(T/F) A claim that has a yellow flag in the Edit Status column in Revenue Management must be corrected before it can be sent to a payer or clearinghouse.
False
– a yellow flag is not serious enough to prevent the claim from being sent, but indicates an increased possibility it will be rejected by the payer
(T/F) A medical necessity denial may result from lack of a clear, correct linkage between the diagnosis and procedure.
True
(T/F) Claims billed to Medicare and then submitted to Medicaid are called coordinated claims.
False
– they are called crossover claims
The HIPAA standard transaction for paper claims is known as the ________________.
CMS-1500 (08/05) Claim
The upper-right corner of the Claim Management dialog box contains five ______________ that simplify the task of moving from one entry to another.
navigator buttons
A ________________ is a condition that data must meet to be selected.
filter
The _____________ method of submitting electronic claims requires manual entry of data on the payer’s website.
direct data entry
Medisoft Network Professional’s __________________ feature allows claims to be reviewed and edited before they are submitted to insurance carriers for payment.
Claim Edit
To perform an edit check on claims in Revenue Management, click _________________ to select the EDI receiver.
Check Claims
Claims billed to Medicare and then submitted to Medicaid are called __________________.
crossover claims
Each claim undergoes a checking process known as _______________ , made up of these steps the health plan follows to judge how it should be paid.
adjudication
A _______________ may result from lack of a clear, correct linkage between the diagnosis and procedure.
medical necessity denial
The ___________________ is the standard electronic transaction to obtain the current status of a claim during the adjudication process.
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response
NUCC
National Uniform Claim Committee
HIPAA X12 276/277
HIPAA Health Care Claim Status Inquiry/Response
HIPAA X12 837
HIPAA Health Care Claim