Ch. 3 Pt. Encounters & Billing Info. Flashcards
New Patient (NP)
patient who has not seen a provider within the past 3 years
Established patient
Patient who has seen a provider (or another provider in the practice with the same specialty) within the past 3 years
5 types of information to gather from new patients
- Preregistration and scheduling info
- Medical history
- Patient or guarantor and insurance data
- Assignments of benefits
- Acknowledgment of Receipt of Notice of Privacy Practices
Physician who transfers care of a patient to another physician
referring physician
Provider who agrees to provide medical services to a payer’s policyholders according to a contract
participating provider (PAR)
Provider who does not join a particular health plan
nonparticipating provider (nonPAR)
Form that includes a patient’s personal, employment, and insurance company data
Patient information form
Insured/subscriber
policyholder of a health plan
guarantor
person who is financially responsible for the bill
Authorization allowing benefits to be paid directly to a provider
Assignment of benefits
Providers do not need specific authorization in order to release patient’s PHI for what purposes?
TPO= Treatment, Payment, Healthcare Operations
Form accompanying a covered entity’s Notice of Privacy Practices for the patient’s signature, indicating that the NPP has been read
Acknowledgment of Receipt of Notice of Privacy Practices
Clinician who treats a patient face-to-face
direct provider
Clinician who does not interact face-to-face with the patient
indirect provider
Unique number that identifies a patient
chart number
PMP
Practice management program
What are the 3 steps to establish patient financial responsibility?
- Verify the patient’s eligibility for insurance benefits.
- Determine preauthorization and referral requirements.
- Determine the primary payer if more than one insurance plan is in effect.
PIF
Patient information form
3 things that are checked before a medical encounter to determine a patient’s eligibility for benefits:
- Patient’s general eligibility for benefits
- The amount of the copayment or coinsurance required at the time of service
- Whether the planned encounter is for a covered service that is medically necessary under the payer’s rules
A website that serves as an entry point to other websites
portal
HIPAA Eligibility for a Health Plan
Also called the X12 270/271; transaction in which a provider asks for (inquiry= 270) and receives an answer (271) about a patient’s eligibility for benefits
Electronic eligibility verification
required payer response to the HIPAA standard transaction
Number assigned to a HIPAA 270 electronic transactions
trace number
Identifying code assigned when preauthorization is required
prior authorization number (also called a certification number)
Authorization number given to the referred physician
referral number
HIPAA Referral Certification and Authorization
HIPAA X12 278 transaction in which a provider asks a health plan for approval of a service and gets a response
Document a patient signs to guarantee payment when a referral authorization is pending
referral waiver
Health plan that pays benefits first
primary insurance
Second payer on a claim
secondary insurance
third payer on a claim
tertiary insurance
health plan that covers services not normally covered by a primary plan
supplemental insurance
Explains how an insurance policy will pay if more than one policy applies
coordination of benefits (COB)
Birthday Rule
guideline stating that the parent whose day of birth is earlier in the calendar year is primary
Gender Rule
guideline that states when a child is covered by 2 health plans, the father’s plan is primary
List of the diagnoses, procedures, and charges for a patient’s visit
encounter form
HIPAA Coordination of Benefits
HIPAA X12 837 transaction sent to a secondary or tertiary payer
Procedures that ensure billable services are recorded and reported for payment
charge capture
TOS payments
Time-of-Service
Participating physician’s agreement to accept allowed charge as full payment
accept assignment
Patient with no insurance
self-pay patient
Payment made during checkout based on an estimate
partial payment
Practice’s rule governing payment from patients
financial policy
real-time adjudication (RTA)
process used to generate the amount owed by a patient
Policy of collecting and retaining patient’s credit card information
credit card on file (CCOF)
