Medical Insurance Chap. 7
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HIPAA X12 837 Health Care Claim: Professional (837P)
form used to send a claim for physician services to primary and secondary payers
CMS-1500
paper claim for physician services
National Uniform Claim Committee (NUCC)
organization responsible for claim content
CMS-1500 (08/05)
current paper claim approved by the NUCC
5010 Version
new format for the EDI transactions
carrier block
data entry area in upper right portion of the CMS-1500
condition code
two-digit numeric or alphanumeric code used to report a special condition or unique circumstance
qualifier
two-digit code for a type of provider identification number other than the NPI
billing provider
provider of health services reported on a claim
pay-to provider
entity that will receive payment for a claim
rendering provider
healthcare professional who provides health services reported on a claim
other ID number
additional provider identification number
outside laboratory
purchased laboratory services
service line information
information about services being reported
place of service (POS) code
administrative code indicating where medical services are provided
administrative code set
required codes for various data elements
taxonomy code
administrative code set used to report a physician's specialty
data element
smallest unit of information in a HIPAA transaction
required data element
information that must be supplied on an electronic claim
situational data element
information that must be on a claim in conjunction with certain other data elements
responsible party
other person or entity who will pay a patient's charges
claim filing indicator code
administrative code that identifies the type of health plan
individual relationship code
administrative code specifying the patient's relationship to the subscriber
destination paper
health plan receiving a HIPAA claim
claim control number
unique number assigned to a claim by the sender
claim frequency code (claim submission reason code)
administrative code that identifies the claim as original, replacement, or void/cancel action
line item control number
unique number assigned to each service line item reported
claim attachment
documentation a provider sends a payer to support a claim
clean claim
claim accepted by a health plan for adjudication
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response
electronic format used to ask payers about claims
claim scrubber
software that checks claims to permit error correction