What is the standard claim form for non-institutional providers?
100
Rules developed to verify the accuracy and completeness of claims based on payor's policies.
What is a claim edit?
100
These inpatient days may be used once by medicare beneficiaries and will never renew.
What are Lifetime Reserve Days, or LTR
100
Hospitals, Rural Health Clinics, Hospice, Skilled Nursing Unit, Clinics, Hospital-based Physicians, and Ambulance.
What are different types of healthcare providers?
100
This happens when a claim cannot be processed for payment due to a number of reasons, including inability to identify the patient, ineligibility of the patient, or non-compliance of the provider with billing requirements.
What is a claim rejection?
200
UB-04
What is the standard claim form for institutional providers?
200
These are typically posted from the midnight census.
What are room and care charges?
200
This program, formerly known as CHAMPUS, is the uniformed services' healthcare program for active duty service members and their families, retired service members and their families, members of the National Guard and Reserve and their families, survivors, and others who are eligible.
What is TRICARE?
200
The rural hospital can alternate its beds between hospital and SNF levels of care if it has obtained this approval from the Department of Health and Human Services.
What is swing-bed approval?
200
The three different types of these are technical, clinical, and underpayment.
What are the three types of denials?
300
81
What is the number of form locators on the UB-04 form?
300
Technology used for translating, standardizing, and sending transactions electronically.
What is the EDI, or Electronic Data Interchange?
300
Claims for non-physician, outpatient services are paid on the basis of these.
What are Ambulatory Payment Classifications, or APCs?
300
Emergency room physicians, anesthesiologists, radiologists, and pathologists.
What are examples of hospital-based physicians?
300
Demographic errors, incomplete or incorrect insurance information, and missing pre-auth are all examples of this type of denial.
What is a technical denial?
400
A claim that is sent to a payor either electronically or on paper, that has no defect, impropriety, or particular circumstance requiring special treatment that prevents prompt payment.
What is a clean claim?
400
Governmental regulations, payor websites, payor-issued specifications, and Payor manuals
What are the items reviewed for the creation of claim edits?
400
This system is is used to classify a discharge based on a patient's condition, and determines the amount paid by Medicare to the provider for inpatient services.
What is the MS-DRG system?
400
THe UB-04 is used for billing for services provided to Medicare beneficiaries, while the CMS-1500 is often required for Medicaid and Commercial Carriers.
What form is used to bill for Rural Health Clinic Services?
400
Diagnosis and procedure performed not matching, service not being medically necessary, and inappropriate level of care are all examples of reasons for this type of denial.
What is a clinical denial?
500
837-I and 837-P
What are the electronic versions of the UB-04 and CMS-1500?
500
Does not include all charges, Includes obsolete or invalid codes, and Does not include required modifiers, all resulting in missed revenue, denials, and/or impacts on reimbursement.
What are typical charge master problems?
500
Emergency services are billed separately from Inpatient claims, Claims must be submitted within 90 days of discharge or of receiving payment from primary payor, and a 10% penalty is deducted if required prior authorization is not obtained.
What are the unique billing requirements of TRICARE?
500
Payable under state or Federal workers compensation, patient not been determined terminally ill, or patient has already used 210 days of this benefit.
What are the reasons for reimbursement denial under hospice care?
500
This group of people usually have the responsibility to manage and reduce claim denials, and must have a method for identifying and monitoring the denials as well as an effective process for reversing and eliminating denials.