1. A(n) electronic claim is submitted to the insurance carrier via the Internet. 2. A(n) Clearinghouse distributes claims to the appropriate insurance carrier. 3. The Carrier-direct electronic claims submission method allows the provider to communicate directly with the insurance company. 4. Compliance monitoring is a process that checks the claim for accuracy and completeness. 5. The clearinghouse assigns a(n) unique identifier to each insurance company (carrier). Provide a short answer for each item. 1. Briefly describe two components of an electronic claims processing agreement.
(1) Must identify provider and insurance carrier responsibilities related to compliance monitoring. (2) Must describe how insurance information is submitted; who has access to the information. 2. List three components of an electronic claims processing agreement required by HIPAA. (1) security features or software that protect information when a wireless network is used. (2) non-redisclosure policies. (3) storage and retention policies. 3. Describe the differences between carrier-direct and clearinghouse electronic claims submission options. Carrier-direct; works directly with the insurance carrier.
Clearinghouse electronic claims are compiled by one company and re-distributed to various carriers. REINFORCEMENT EXERCISES 10–2 Provide a short answer for each item. 1. List three types of information required by nearly all insurance carriers. (1) Patient demographic information. (2) Insurance program information. (3) Treatment or clinical information. 2. Describe two edits often included in insurance billing software. (1) Edits evaluation and management (E/M) code that is not supported by the diagnosis and treatment codes. (2) Invalid diagnosis and treatment codes. 3.
Identify sources and source documents for retrieving information for electronic claims submission. Source documents, such as the encounter form, patient registration documents, and the patient’s record. Write true or false for each statement. 1. The CMS-1500 is made obsolete when using electronic claims submission. TRUE 2. Electronic claims submission software programs edit insurance claims data for accuracy. FALSE 3. A pattern of coding errors can trigger an investigation of fraud or abuse. TRUE 4. The provider is responsible for assigning accurate diagnostic and procedure codes.
TRUE 5. Interactive communication is a time-consuming way to identify and correct insurance claims data. FALSE REINFORCEMENT EXERCISES 10–3 Write true or false for each statement. 1. Confidentiality laws for paper records do not apply to electronic records. FALSE 2. Staff members should share a common password for efficient access to insurance files. FALSE 3. Confidential information should never be stored on a computer’s hard drive. TRUE 4. A written policy should address electronic claims submission and confidentiality. TRUE 5.
Electronic records management systems include the same components as a record management system for paper files. TRUE Fill in the blank. 1. Electronic records are usually filed by a unique patient identification number and patient name. 2. Records must be backed up regularly. 3. All records—either electronic or paper—must be stored in a(n) secure and safe area. 4. Computer monitor privacy screens are one of the tools available to protect confidential information. 5. Passwords assigned to previous employees should be deleted from all electronic or computer program files.