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Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 08 The Electronic Claim Insurance Handbook for the Medical Office.

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Presentation on theme: "Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 08 The Electronic Claim Insurance Handbook for the Medical Office."— Presentation transcript:

1 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 08 The Electronic Claim Insurance Handbook for the Medical Office 13 th edition

2 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

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

4 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Electronic Data Interchange  Used for transmission of health insurance claims  Transmitted data is encrypted  Improves efficiency of claims submissions 4

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

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

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

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

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

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

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

12 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Standard Unique Identifiers  Standard unique employer identifier  Standard unique healthcare provider identifier  Standard unique health plan identifier  Standard unique patient identifier 12

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

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

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

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

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

18 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Encoder  Signature requirements  Physician  Patient 18

19 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Clean Electronic Claims Submission  Claim scrubber software  Encoder software  Electronic clearinghouse  Single and batch claims review 19

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

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

22 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Interactive Transactions  Back-and-forth communication between two computer systems  Real time communication allows instant information transfer 22

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

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

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

26 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Methods for Sending Claims  Cable modem  Digital subscriber line (DSL)  T-1  Direct data entry (DDE)  Application service provider (ASP) 26

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

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

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

30 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Administrative Simplification Enforcement Tool  Online tool  Assists healthcare providers, payers, clearinghouses, and others to submit complaints regarding the HIPAA TCS rule 30

31 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved The Security Rule: Administrative, Physical, and Technical Safeguards  Administrative safeguards  Information access controls  Internal audits  Risk analysis and management  Termination procedures 31

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

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

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

35 Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 35


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