What did you learn_
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School
Platt College, Ontario *
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Course
MAS 107
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
4
Uploaded by BarristerHawkMaster824
1
What did you learn?
Health Insurance Today textbook
Ch_05 - Claim Submissions Method
As you read the chapter, answer the What did you learn? sections located on the
pages stated below.
Page 65, 67, 69, 80, 82, 87
Page 65
1. The health insurance claims process is an interaction between
the healthcare provider and an insurance company.
2. After the patient visit, information from the record is transmitted to the insurance company in the form of a
claim.
3. Provide an accurate definition for “medical necessity.”
To meet the medical necessity criteria, services or supplies
must be appropriate and necessary for the symptoms, diagnosis, and/or treatment of the medical condition, and they
must meet the standards of good medical practice.
4. Name the two basic claim submission methods.
electronic and paper
Page 67
1. What type of software was instrumental in the expansion of electronic claims?
Practice management software.
2. Name the important legislation Congress passed in 1996 that significantly affected medical billing and claims
submission.
HIPPA
3. List who is included in the designation “covered entity.”
●
healthcare provider
●
health plan
●
healthcare clearinghouse.
4. What are the four exceptions to ASCA’s electronic claims submission requirement?
●
roster billing of Medicare-covered vaccinations,
●
dental claims,
●
claims in which there are two or more primary plans and Medicare is secondary, and
●
service interruptions beyond the control of the provider
5. Name the four parts to HIPAA’s Administration Simplification Act.
2
●
Electronic transactions and code sets standards requirements
●
Privacy requirements
●
Security requirements
●
National identifier requirements
6. True or
false
: The NPI and the EIN are basically the same and can be used interchangeably on claims.
Page 69
1. After January 2012, providers who submit claims electronically must use Standard Version
5010.
2. List the entities that are affected by the switch to the HIPAA Standards Version.
• physicians,
• hospitals,
• ancillary care and behavioral health providers,
• third-party payers (insurance companies),
• claims clearinghouses,
• pharmacies, and
• dentists.
3. The Standards Version supports the reporting of
NPI’S
and
The new ICD
codes.
4. True or
false
: ASCA requires that all claims submitted to the Medicare program be submitted in electronic form,
with no exceptions.
5. Physicians who qualify for exclusion under the
small-provider
exemption may continue sending paper claims.
Page 80
1. When does the insurance claims process begin?
when the patient arrives at the medical facility, at which time he
or she is given various forms to read and fill out.
2. List the information/documents essential for claims processing.
●
Patient Information Form
●
Patient Insurance Identification Card
●
Patient Health Record
●
Encounter Form
●
Patient Ledger Card
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