| ADJUDICATION:
Steps followed by an insurance company to process a
claim.
BROWSER: A software program that interprets
documents written in HTML the main programming language
of the World Wide Web. A browser such as Netscape or
Microsoft Explorer is required to experience the photos,
video and sound elements on a web page and assists in
quick, easy travel around the world.
CLEARINGHOUSE: An agent between a
provider and a payer that takes claims and other electronic
data from providers, verifies the data integrity of
the information, and forwards the proper forms to the
payers. More than a transfer station, a clearinghouse
acts as a fact-checker and a data format translator.
It accepts and forwards electronic transmissions to
insurance companies. The clearinghouse formats the data
into the HIPAA 837 format, then batches the claims by
payer and transmits them to each payer. It is an entity
providing electronic connectivity to any number of payers.
Providers can transmit all claims directly to a clearinghouse.
Examples of clearinghouses are RECS, Envoy, Professional
Alliance and Dentec/Softech. Some Practice Management
System vendors also provide clearinghouse services.
Examples of PMS vendors with clearinghouse capabilities
are Professional Alliance and Dentec/Softech.
CONNECTIVITY: Software used to link
personal computers to create a local area network (LAN).
DELTALINK: Delta Dental's trademarked
name for the process of electronic data transmission
between Delta Dental and different clearinghouses primarily
associated with electronic claims.
DENTAL OFFICE TOOLKIT (DOT): Free
online (Internet) service that allows providers the
ability to submit claims and predeterminations, check
claims status, review eligibility and benefits information
and utilize Direct Deposit (EFT) of claims payments.
DIRECT DEPOSIT: See Electronic
Funds Transfers.
ELECTRONIC CLAIM: The paperless submission
of claims by using a specialized application.
ELECTRONIC CLAIMS SUBMISSION (ECS):
Transmitting dental claims for adjudication (transfer
of a request for payment and/or predetermination) from
a practice to a payer. The dental office transmits claims
to their clearinghouse, the clearinghouse reformats
the data into the 837 format and transmits the claims
on to the payers.
ELECTRONIC DATA INTERCHANGE (EDI):
The conventional exchange of business transactions,
documents or data over communications media using the
HIPAA 837 electronic format from computer to computer.
This means utilizing sophisticated software to transfer
data through a telephone line from one computer to another.
Dental claims are not transmitted directly to us. The
dental office transmits claims to their clearinghouse;
the clearinghouse reformats the data into the 837 format
and transmits the claims on to the payers.
ELECTRONIC FUNDS TRANSFER:
The transfer of payments directly into a provider's
financial institution account rather than mailing out
paper checks.
HARDWARE: A coordinated grouping of
electrical equipment that performs specific tasks as
specified by its user. For example, printers, keyboards
monitors (screens) and the computer.
HEALTH INSURANCE PROTABILITY AND ACCOUNTABILITY
ACT OF 1996 (HIPAA): A federal law that defines
standard formats for certain health insurance transactions.
MODEM: A communications device that
converts a computer's digital signals to transferable
analog signals sent over a telephone line.
OPERATING SYSTEM: Computer software
responsible for controlling the allocation and use of
hardware resources and the execution of application
programs. Examples of operating systems are Windows,
DOS and UNIX.
PRACTICE MANAGEMENT SYSTEM (PMS):
It is a generic reference to a software system that
assists in the overall management of the practice. Examples
of dental PMS are PracticeWorks, InfoSoft, SoftDent,
Dentec/Softech and Professional Alliance. Some examples
of PMS vendors with clearinghouse capabilities are Professional
Alliance and Dentec/Softech.
PRACTICE MANAGEMENT SOFTWARE: See
Practice Management System.
PRACTICE MANAGEMENT SOFTWARE VENDOR:
The company where the software comes and who you call
for service.
PAYER: A payer is any insurance or
dental benefits carrier. Examples of payers are Delta Dental of Michigan, Blue Cross Blue Shield and
MetLife.
SERVER: A computer that manages the
resources on a network, controlling access to the software,
printer and other devices as well as providing a centralized
storage area for programs and data.
SOFTWARE: A collection of instructions
(programming) with a friendly, easy to use interface
that allows a user to perform specific tasks which processes
data into information.
|
