CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing Flashcards

What is the standard electronic claim format used for professional physician billing to Medicare?

Answer: CMS-1500 transmitted as 837P

The CMS-1500 paper form and its electronic equivalent the 837P transaction are used for professional billing.

What information is captured in the place of service code on a CMS-1500 claim?

Answer: The setting where the service was rendered such as office or outpatient hospital

Place of service codes indicate where a service was provided, which affects payment rates for many payers.

Which position on a claim form identifies the diagnosis primarily responsible for the patient visit?

Answer: The principal diagnosis code in the first position

The first-listed or principal diagnosis code identifies the primary reason for the encounter and drives medical necessity determination.

What is the purpose of a clean claim standard in healthcare billing?

Answer: To define the minimum data elements required for a claim to be processed without additional information

A clean claim contains all required information for the payer to process it without requesting additional data, which speeds up payment.

A claim is submitted electronically and the practice receives a 277CA transaction. What does this indicate?

Answer: The claim acknowledgment status showing whether it was accepted or rejected by the payer

The 277CA is the Claims Acknowledgment transaction that tells the submitter whether the payer accepted or rejected the claim at the front end.

What is coordination of benefits in claims processing?

Answer: The process of determining the order in which multiple insurance plans pay on a claim

COB rules determine which payer is primary and which is secondary when a patient has more than one insurance plan.