Medical Insurance Chap. 7

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created 6 years ago by kmak
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1

HIPAA X12 837 Health Care Claim: Professional (837P)

form used to send a claim for physician services to primary and secondary payers

2

CMS-1500

paper claim for physician services

3

National Uniform Claim Committee (NUCC)

organization responsible for claim content

4

CMS-1500 (08/05)

current paper claim approved by the NUCC

5

5010 Version

new format for the EDI transactions

6

carrier block

data entry area in upper right portion of the CMS-1500

7

condition code

two-digit numeric or alphanumeric code used to report a special condition or unique circumstance

8

qualifier

two-digit code for a type of provider identification number other than the NPI

9

billing provider

provider of health services reported on a claim

10

pay-to provider

entity that will receive payment for a claim

11

rendering provider

healthcare professional who provides health services reported on a claim

12

other ID number

additional provider identification number

13

outside laboratory

purchased laboratory services

14

service line information

information about services being reported

15

place of service (POS) code

administrative code indicating where medical services are provided

16

administrative code set

required codes for various data elements

17

taxonomy code

administrative code set used to report a physician's specialty

18

data element

smallest unit of information in a HIPAA transaction

19

required data element

information that must be supplied on an electronic claim

20

situational data element

information that must be on a claim in conjunction with certain other data elements

21

responsible party

other person or entity who will pay a patient's charges

22

claim filing indicator code

administrative code that identifies the type of health plan

23

individual relationship code

administrative code specifying the patient's relationship to the subscriber

24

destination paper

health plan receiving a HIPAA claim

25

claim control number

unique number assigned to a claim by the sender

26

claim frequency code (claim submission reason code)

administrative code that identifies the claim as original, replacement, or void/cancel action

27

line item control number

unique number assigned to each service line item reported

28

claim attachment

documentation a provider sends a payer to support a claim

29

clean claim

claim accepted by a health plan for adjudication

30

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response

electronic format used to ask payers about claims

31

claim scrubber

software that checks claims to permit error correction