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Lifecycle of a Medical Claim

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Lifecycle of a Medical Claim

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25 Questions

1. Internal audit

The joint commissionElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formAn audit performed by personnel within a healthcare provider organization- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

2. Adjudication

The joint commission- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

3. The official ub-04 data specifications manual

An audit performed by personnel within a healthcare provider organizationThe joint commissionElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

4. A routine or random audit to check the healthcare provider's compliance with rules and regulations

- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formAn audit performed by personnel within a healthcare provider organizationThe joint commission

5. Submission

Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formAn audit performed by personnel within a healthcare provider organization- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).The healthcare provider sends the claim to the third-party payer requesting payment (usually done electronically)

6. National coverage determinations (ncds)

Describe whether medicare pays for specific medical items - services - treatment procedures or technologies- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formAn audit performed by personnel within a healthcare provider organization

7. National plan and provider enumeration system

Assign unique identifying numbers to all healthcare providersAn audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

8. Clean claim

Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formClean claim is a complete and accurate claim form that includes all provider and member information - as well as records - additional information - or documents needed from the member or provider to enable the payer to process the claimAn audit performed by personnel within a healthcare provider organization- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

9. Explanation of benefits (eob)

One patient's explanation of the paid services- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

10. Department of justice (doj)

- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formDoj is an independent law enforcement agency - prosecutes fraud and abuse

11. Step for individual and small group practices to create and maintain a voluntary regulatory compliance program: .Conduct Internal monitoring and auditing through the performance of periodic audits. 2.Implement Compliance and practice standards through the development of written standards and procedures. 3.Designate A compliance officer or contact(s) to monitor compliance efforts and to enforce practice standards. 4.Conduct Appropriate training and education on practice standards and procedures. 5.Respond Appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities. 6.Develop Open lines of communication - such as discussions at staff meetings - regarding how to avoid erroneous or fraudulent conduct to keep employees updated regarding compliance activities. 7.Enforce Disciplinary standards through well-publicized guidelines.

An audit performed by personnel within a healthcare provider organization- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).UndercodingElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

12. Cms-1500

- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formClaim form used to bill professional services: surgeon's fees for a surgery performed at an outpatient surgery center or an emergency physician's fee for professional services provided in the emergency room.

13. Types of bills (tobs)

These numbers are 4 digits in length and the first digit is always a zero - the zero is not used when filing the ub-04 electronically. The other digits refer to the type of facility - the classification of the bill - and the frequency of the bill- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

14. Electronic data interchange (edi)

An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).Data to be transferred between different computer systems or computer networks

15. Revenue codes

An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formAre used to describe services rendered during treatment.- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

16. The office of inspector general (oig)

- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organizationMonitors for compliance and turns suspected fraud and abuse over to the dojElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

17. Eob statement has three sections

Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form1. Service information 2. Coverage determintion 3. Benefit payment information- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organization

18. Reconciliation

An audit performed by personnel within a healthcare provider organizationThe healthcare provider analyzes received payment information compared to submitted claim information for accuracyElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

19. Review that deals with completeness—is the documentation thorough and complete

Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).Recovery audit contractor program (rac)An audit performed by personnel within a healthcare provider organization

20. Clearinghouse

Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formA company contracted by the third-party payers to handle and format submissions - screen claims - and make data available to providers.- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organization

21. Payment

A financial payment is made by the third party payer and received by the providerElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formAn audit performed by personnel within a healthcare provider organization- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

22. An independent - not-for-profit organization - the joint commission accredits and certifies more than 15 - 000 healthcare organizations and programs in the united states. Joint commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards

An audit performed by personnel within a healthcare provider organizationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the formQualitative analysis- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).

23. National uniform claim committee (nucc)

Created in 1995 to develop a standardized data set for use by the non-institutional health care community to transmit claim and encounter information to and from all third-party payersAn audit performed by personnel within a healthcare provider organization- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).Electronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

24. Steps in a medical claim

- third-party payer's process of checking the details of the claim against the information they have on the patient and his/her insurance benefits - checks for completeness of the claim - bundling issues for cpt® codes - medical necessity - and recent claims (to avoid unnecessary service or duplicate claims).An audit performed by personnel within a healthcare provider organization1 submission 2 processing 3 adjudication 4 payment 5 reconciliationElectronic handbook created by the national uniform billing committee that explains and defines each form locator and explains how to properly complete the form

25. Retrospective review:

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25 Questions

❤ If you liked Fatskills, consider supporting us by checking out The Life Manuals You Never Got.

About | Explore | User Guide | Topics | Subjects | Doubt Solver | Career Aptitude Test | Answers | Free Tools | OSHA Basics Quiz | What Should We Know? Privacy | Terms |

Without work one finishes nothing. - Ralph Waldo Emerson© 2026 Fatskills.com

All trademarks, logos and brand names are the property of their respective owners. All company, product and service names used in this website are for identification purposes only. Use of these names, trademarks and brands does not imply endorsement.

About | Explore | User Guide | Topics | Subjects | Doubt Solver | Career Aptitude Test | Answers | Free Tools | OSHA Basics Quiz | What Should We Know?
Privacy | Terms |

Without work one finishes nothing. - Ralph Waldo Emerson
© 2026 Fatskills.com