Chapter 27 — Exercises

How to use these. Section B is memorization and there is no way around it — drill it until the transaction numbers are automatic, because everyone who can help you with a pipeline problem uses them.

Section D is the transferable one. Translating a rejection message from the transaction's vocabulary into the form's is the skill Chapter 25's Case Study 1 needed and did not have.

And Section F should be answered before Section G, because the rejection/denial distinction is the one error in this chapter that costs real money.

Section A — What HIPAA did and did not standardize (items 1–9)

A.1 What did HIPAA's Administrative Simplification provisions require?

A.2 Name four things the standards fixed and four things they did not.

A.3 What are the three requirement levels an implementation guide assigns a data element? Which one causes the trouble, and why?

A.4 What document tells you a specific payer's answer? Name the three earlier chapters that already told you to read it.

A.5 Besides transactions, name the two other things Administrative Simplification standardized.

A.6 Which chapters of this book were, without saying so, a tour of the HIPAA code sets?

A.7 A claim fails. Name the three independent things that could be wrong, and say why a terse rejection message may not distinguish them.

A.8 What was the 4010-to-5010 transition, and why is a version change "an industry event rather than a software update"?

A.9 What do the operating rules add, and what problem do they exist to solve?

Section B — The transaction set (items 10–20)

B.10 Give the transaction for: eligibility inquiry · eligibility response · claim status inquiry · claim status response · prior authorization · remittance advice.

B.11 What are the 837P, 837I, and 837D?

B.12 What is the 999? The TA1?

B.13 What is the 277CA, and how does it differ from a 277?

B.14 State the memory hook for the paired transactions.

B.15 Which transaction is the only one that carries payment information back, and which chapter owns it?

B.16 What is the 834, and why does a biller ever care about it?

B.17 A payer's system reports a claim's status as "finalized/denied." Which transaction is that, and what does it not contain that you need?

B.18 (Chapter 24) Which transaction have you been using since Chapter 24 without being told its name?

B.19 Which two transactions would you use to answer: "Will this payer approve the MRI?" and "Did the payer ever get my claim?"

B.20 Name the three acknowledgments in the order they occur.

Section C — The 837 (items 21–28)

C.21 Complete: "An 837 is not a picture of a form. It is _______."

C.22 Name three things the 837I carries that the 837P does not.

C.23 Name one thing the 837P carries that the 837I does not, and say why the institutional claim does not need it.

C.24 (Chapter 25) A paper CMS-1500 has six service lines. Is the 837P limited to six? What follows for a system that says a claim must be split?

C.25 (Chapter 14) Where do the four modifier positions live in the transaction? What does that tell you about the origin of the four-modifier rule?

C.26 What is a loop? A segment? A data element?

C.27 Translate: "Loop 2400, SV107."

C.28 Translate: "Loop 2010BA, NM109 is missing." Give the item number on the form.

Section D — Reading a rejection (items 29–38)

D.29 Give the form's equivalent for each: Loop 2300 HI · Loop 2400 SV102 · Loop 2310A NM109 · Loop 2010AA NM109 · Loop 2400 SV101-3.

D.30 In SV1*HC:99214:25*185.00*UN*1***1:2:3:4~, identify the qualifier, the procedure code, the modifier, the charge, the units, and the pointers.

D.31 The pointers on the form are letters and in the transaction are numbers. Are they different information? Explain.

D.32 What does an empty position between two delimiters mean? Why does that let a payer reject an element you never populated?

D.33 Translate and give the fix: Loop 2300, HI01-2 — invalid code. Name two likely causes.

D.34 Translate and give the fix: Loop 2400, SV101-3 — invalid modifier. Distinguish this message from a payer denying a modifier.

D.35 Translate and give the fix: Loop 2010BA, DMG02 — missing.

D.36 Translate: Loop 2400, SV107 — pointer references a diagnosis not present on the claim. What can the transaction detect here, and what can it never detect?

D.37 (Chapter 25) A rejection names Loop 2310A NM109 on Account 10-4471's claim. What is the most likely cause, and what is the fix?

D.38 Name the four things to check on an invalid-referring-provider rejection, in order. Which one cannot be fixed by billing?

Section E — Clearinghouses and enrollment (items 39–48)

E.39 Define a clearinghouse. Why does one exist even though the format is standardized?

E.40 Name the four things a clearinghouse does for you.

E.41 What does it mean that a clearinghouse "fixes things silently"? Name the three ways that hurts you.

E.42 Why is failing at the clearinghouse better than failing at the payer? Give two reasons.

E.43 Are clearinghouse edits the payer's edits? What does passing them prove, and what does it not?

E.44 A clearinghouse's edit list and a payer's companion guide disagree. Which is authoritative? Which is usually more current? Is that a contradiction?

E.45 Name the three enrollments, what each permits, and the level at which they exist.

E.46 A practice submits claims electronically and receives paper checks with paper remittances. Which enrollment is missing, and which chapter's process is impossible without it?

E.47 What should you ask your clearinghouse to produce, and what will the gaps in it tell you?

E.48 Three things happen at once when a practice changes clearinghouses. Name them, say which one is never planned for, and state the two practical instructions.

Section F — Acknowledgments (items 49–56)

F.49 State the question each acknowledgment answers: TA1 · 999 · 277CA.

F.50 What are the three possible 999 outcomes?

F.51 Complete and explain: "A 999 acceptance is not proof that _______."

F.52 Give three reasons a claim can pass the 999 and be rejected by the 277CA.

F.53 A report shows: TA1 accepted · 999 accepted, 38 claims · 277CA accepted 36, rejected 2. How many claims were transmitted? How many were submitted? Why does the difference matter?

F.54 Decode A7:562 on a rendering provider. Name the three parts of a 277CA message.

F.55 Why does the entity identifier matter as much as the status code? Contrast a rejection naming the referring provider with one naming the billing provider.

F.56 State the four questions to ask your clearinghouse, and say what Chapter 25's Case Study 1 cost because nobody had asked them.

Section G — Rejection versus denial (items 57–64)

G.57 Give the six-row contrast between a rejection and a denial.

G.58 Which row is the expensive one, and why is it the opposite of most people's intuition?

G.59 Why does a rejection have no CARC or RARC? What vocabulary describes it instead?

G.60 Why does a rejection not appear in your denial rate? What does that do to a practice's self-assessment?

G.61 Estimate the minutes to fix a rejection on day 1 and on day 120. State the structural principle both figures illustrate.

G.62 Why is a rejection found at day 120 evidence of more than one problem?

G.63 Name the four kinds of proof of timely filing, in descending order of strength. Which is the strongest, and why do most practices offer the weakest?

G.64 A claim was rejected on day 2 and resubmitted on day 200 against a ninety-day window. You have a 277CA. Whose position does it establish? What are the two preventive defenses?

Section H — Attachments, modes, and status (items 65–70)

H.65 State the attachment situation honestly: name the 275, esMD, and the two non-standard methods that work.

H.66 Describe the failure where the claim and the document both arrive and are never joined. Name the three defenses.

H.67 Distinguish batch from real time. Which mode is used for claims, which for eligibility, and why?

H.68 Name two legitimate uses of the 276.

H.69 Why is running automatic status inquiries on every claim a bad habit? What is the sharper version of that criticism?

H.70 State the reasonable default for using the 276.

Section I — The Encounter through the pipeline (items 71–76)

I.71 (Chapter 6) Give the four days from service to acknowledgment and what happens on each.

I.72 What exists at the end of day 0? Why is that the most consequential day on the list?

I.73 At what time is the 837P transmitted, and what does that tell you about where the elapsed time goes?

I.74 Both acknowledgments were positive on day 3 and line 1 was denied on day 17. Is that a contradiction? Explain in one sentence.

I.75 Name the three things the pipeline checked, and state precisely what none of them evaluated.

I.76 Same-day submission would have saved about a day. Why does that matter much less than it sounds like it should?