This unique resource takes readers from the paper-based world of health care claims and gives them the data content knowledge necessary for reporting claims in the HIPAA environment. In clear language, this resource examines the CMS 1500 claim form in detail, gives a brief overview of the electronic transactions standards mandated by the U.S. Department of Health and Human Services.
This book also provides a comprehensive education on particular elements not found in other HIPAA publications, particularly the non-medical code sets required under HIPAA. These code sets include:
- Provider Taxonomy. Required by more and more Insurance Companies, Provider Taxonomy is a standard administrative code set for identifying the provider type and area of specialization for all health care providers. A complete list of the Provider Taxonomy code set is included in this publication.
- Claim Adjustment Reason. This code set is used to communicate why a claim or service line was "adjusted", which means why a claim or service line was paid differently than it was billed.
- Remittance Advice Remark. This code set adds greater specificity to a Claim Adjustment Reason Code. Remark Codes are used in a remittance advice to relay informational messages that cannot be expressed with a Claim Adjustment Reason Code.
- Claim Status Category. This code set indicates the general category of the status of a claim within the adjudication process (eg, accepted, rejected, additional information requested, etc).
- Claim Status. This code set further communicates information about the status of a claim.
- Place-of-Service. This code set specifies the entity where service(s) are rendered.
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