#1
What is a Health Care Claim?
A request for payment of medical services provided to a patient
ExplanationIt is a formal request for reimbursement of medical services rendered to a patient.
#2
In health care claim processing, what is a 'payer'?
An entity responsible for processing and paying claims
ExplanationA 'payer' is an entity responsible for processing and making payments for health care claims.
#3
Which organization oversees health care claim processing standards in the United States?
American Medical Association (AMA)
ExplanationThe AMA is responsible for setting and maintaining standards for health care claim processing in the United States.
#4
What is a common format for electronic health care claims in the United States?
ANSI ASC X12N
ExplanationANSI ASC X12N is a widely used standard format for electronic health care claims in the United States.
#5
What is the purpose of a clearinghouse in health care claim processing?
To convert claim data into a standard format and transmit it to payers
ExplanationClearinghouses play a crucial role in converting and transmitting health care claim data in a standardized format to facilitate processing by payers.
#6
What is a Health Maintenance Organization (HMO) in the context of health care claims?
A type of insurance plan that requires patients to use only in-network providers
ExplanationHMOs are insurance plans that restrict coverage to in-network providers, promoting cost-effective and coordinated care.
#7
What is a remittance advice in health care claim processing?
A notice sent to a healthcare provider detailing the results of claims processing
ExplanationRemittance advice is a communication to healthcare providers summarizing the outcome of claims processing, including payment details.
#8
What is the purpose of Electronic Data Interchange (EDI) in health care claim processing?
To convert claim data into a standard format for transmission
ExplanationEDI converts health care claim data into a standardized format, facilitating efficient electronic transmission between parties.
#9
What is meant by the term 'clean claim' in health care claim processing?
A claim submitted with complete and accurate information
ExplanationA 'clean claim' refers to a submission with all necessary and accurate information, streamlining the processing and payment.
#10
What role does the National Provider Identifier (NPI) play in health care claim processing?
It is a unique identifier for healthcare providers
ExplanationThe NPI serves as a unique identification for healthcare providers, aiding in accurate and standardized claim processing.
#11
What is Coordination of Benefits (COB) in health care claim processing?
A process to determine which insurance plan is primary when a patient has coverage under more than one plan
ExplanationCOB is the process of deciding the primary insurance plan when a patient has coverage under multiple plans.
#12
What is the purpose of the Health Insurance Portability and Accountability Act (HIPAA) in relation to health care claims?
To ensure patient confidentiality and protect health information
ExplanationHIPAA safeguards patient confidentiality and protects health information, ensuring privacy in health care claims processing.
#13
What is a Common Procedural Terminology (CPT) code used for in health care claim processing?
To describe medical procedures and services
ExplanationCPT codes are used to describe and identify specific medical procedures and services in health care claims.
#14
What is a Health Savings Account (HSA) used for in relation to health care claim processing?
To pay for qualified medical expenses with pre-tax dollars
ExplanationHSAs allow individuals to use pre-tax dollars to cover qualified medical expenses, providing a tax-advantaged approach to managing healthcare costs.