AAPC CPB Medical Billing Chapter 1
Intro to Healthcare
8 STANDARD TRANSACTIONS FOR EDI - ANS - CLAIMS/ENCOUNTER,
PAYMENT REMIT,
CLAIM STATUS,
ELIGIBILITY,
ENROLLMENT,
REFERRALS/AUTH,
COB,
PREMIUM PAYMENTS- MUST USE ASCX12 VERSION 5010
A covered entity may not use or disclose PHI unless - ANS - - the privacy rule permits
it
- the individual authorizes in writing
A healthcare clearing house is a - ANS - entity that processes nonstandard health
information they receive from another entity into a standard format
Abuse - ANS - action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
Administrative requirements - ANS - - all covered entities must have written privacy
policies that comply with the Privacy Rule
- A privacy official must be designated
- all members of a covered entity's workforce must be trained
- covered entities are required to mitigate any harmful effect that may have been caused
by inappropriate use or disclosure of PHI
- procedures must be in place to allow an individual to complain about a covered entity's
compliance
- A covered entity may not retaliate against a person for exercising his or her rights
provided by the Privacy Rule
- Privacy policies must be maintained by covered entities for 6 years, after the later of
the date of their creation, or last effective date
- fully insured group health plans have only 2 obligations
, - refrain from retaliatory acts and waiver of individual rights
- to provide documentation for the disclosure of PHI through documentation
Anti-Kickback Law - ANS - Prohibits the solicitation, receiving, offering, or paying of
any remuneration directly or indirectly in cash or in kind in exchange.
ARRA - ANS - American Recovery and Reinvestment Act
Business associate covered entity - ANS - limited to legal, actuarial, accounting,
consulting, data aggregation, management, administrative, accreditation, or financial
services
Business associates - ANS - Perform certain functions or activities which involve the
use or disclosure of individually identifiable health information on behalf of another
person or organization
CDT - ANS - Current Dental Terminology
CMS Requirements - ANS - - medical records must be retained in their original or
legally reproduced form for a period of at least 5 years
- for providers submitting cost reports to be retained their original or legally reproduced
form for a period of at least 5 years after the closure of the cost report
- for managed care program, providers should retain records for 10 years
Code Sets - Coding Systems - ANS - A term particularly used for those codes
approved by HIPAA regulations for use in electronic transactions
Code sets adopted - ANS - Healthcare common procedure coding system
Current procedure terminology
International Classification of Diseased
National drug codes
Current dental terminology
Place of service codes
Conditions of Participation (CoP) - ANS - designed to protect patient health and safety
and to ensure quality of care
covered entities under HIPAA - ANS - health plans, healthcare clearinghouses, and
any healthcare provider who transmits health information in an electronic format
Intro to Healthcare
8 STANDARD TRANSACTIONS FOR EDI - ANS - CLAIMS/ENCOUNTER,
PAYMENT REMIT,
CLAIM STATUS,
ELIGIBILITY,
ENROLLMENT,
REFERRALS/AUTH,
COB,
PREMIUM PAYMENTS- MUST USE ASCX12 VERSION 5010
A covered entity may not use or disclose PHI unless - ANS - - the privacy rule permits
it
- the individual authorizes in writing
A healthcare clearing house is a - ANS - entity that processes nonstandard health
information they receive from another entity into a standard format
Abuse - ANS - action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
Administrative requirements - ANS - - all covered entities must have written privacy
policies that comply with the Privacy Rule
- A privacy official must be designated
- all members of a covered entity's workforce must be trained
- covered entities are required to mitigate any harmful effect that may have been caused
by inappropriate use or disclosure of PHI
- procedures must be in place to allow an individual to complain about a covered entity's
compliance
- A covered entity may not retaliate against a person for exercising his or her rights
provided by the Privacy Rule
- Privacy policies must be maintained by covered entities for 6 years, after the later of
the date of their creation, or last effective date
- fully insured group health plans have only 2 obligations
, - refrain from retaliatory acts and waiver of individual rights
- to provide documentation for the disclosure of PHI through documentation
Anti-Kickback Law - ANS - Prohibits the solicitation, receiving, offering, or paying of
any remuneration directly or indirectly in cash or in kind in exchange.
ARRA - ANS - American Recovery and Reinvestment Act
Business associate covered entity - ANS - limited to legal, actuarial, accounting,
consulting, data aggregation, management, administrative, accreditation, or financial
services
Business associates - ANS - Perform certain functions or activities which involve the
use or disclosure of individually identifiable health information on behalf of another
person or organization
CDT - ANS - Current Dental Terminology
CMS Requirements - ANS - - medical records must be retained in their original or
legally reproduced form for a period of at least 5 years
- for providers submitting cost reports to be retained their original or legally reproduced
form for a period of at least 5 years after the closure of the cost report
- for managed care program, providers should retain records for 10 years
Code Sets - Coding Systems - ANS - A term particularly used for those codes
approved by HIPAA regulations for use in electronic transactions
Code sets adopted - ANS - Healthcare common procedure coding system
Current procedure terminology
International Classification of Diseased
National drug codes
Current dental terminology
Place of service codes
Conditions of Participation (CoP) - ANS - designed to protect patient health and safety
and to ensure quality of care
covered entities under HIPAA - ANS - health plans, healthcare clearinghouses, and
any healthcare provider who transmits health information in an electronic format
