Ch. 3 Pt. Encounters & Billing Info.

Question 1

New Patient (NP)

Answer 1

patient who has not seen a provider within the past 3 years

Question 2

Established patient

Answer 2

Patient who has seen a provider (or another provider in the practice with the same specialty) within the past 3 years

Question 3

5 types of information to gather from new patients

Answer 3

1. Preregistration and scheduling info
2. Medical history
3. Patient or guarantor and insurance data
4. Assignments of benefits
5. Acknowledgment of Receipt of Notice of Privacy Practices

Question 4

Physician who transfers care of a patient to another physician

Answer 4

referring physician

Question 5

Provider who agrees to provide medical services to a payer’s policyholders according to a contract

Answer 5

participating provider (PAR)

Question 6

Provider who does not join a particular health plan

Answer 6

nonparticipating provider (nonPAR)

Question 7

Form that includes a patient’s personal, employment, and insurance company data

Answer 7

Patient information form

Question 8

Insured/subscriber

Answer 8

policyholder of a health plan

Question 9

guarantor

Answer 9

person who is financially responsible for the bill

Question 10

Authorization allowing benefits to be paid directly to a provider

Answer 10

Assignment of benefits

Question 11

Providers do not need specific authorization in order to release patient’s PHI for what purposes?

Answer 11

TPO= Treatment, Payment, Healthcare Operations

Question 12

Form accompanying a covered entity’s Notice of Privacy Practices for the patient’s signature, indicating that the NPP has been read

Answer 12

Acknowledgment of Receipt of Notice of Privacy Practices

Question 13

Clinician who treats a patient face-to-face

Answer 13

direct provider

Question 14

Clinician who does not interact face-to-face with the patient

Answer 14

indirect provider

Question 15

Unique number that identifies a patient

Answer 15

chart number

Question 16

PMP

Answer 16

Practice management program

Question 17

What are the 3 steps to establish patient financial responsibility?

Answer 17

1. Verify the patient’s eligibility for insurance benefits.
2. Determine preauthorization and referral requirements.
3. Determine the primary payer if more than one insurance plan is in effect.

Question 18

PIF

Answer 18

Patient information form

Question 19

3 things that are checked before a medical encounter to determine a patient’s eligibility for benefits:

Answer 19

1. Patient’s general eligibility for benefits
2. The amount of the copayment or coinsurance required at the time of service
3. Whether the planned encounter is for a covered service that is medically necessary under the payer’s rules

Question 20

A website that serves as an entry point to other websites

Answer 20

portal

Question 21

HIPAA Eligibility for a Health Plan

Answer 21

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

Question 22

Electronic eligibility verification

Answer 22

required payer response to the HIPAA standard transaction

Question 23

Number assigned to a HIPAA 270 electronic transactions

Answer 23

trace number

Question 24

Identifying code assigned when preauthorization is required

Answer 24

prior authorization number (also called a certification number)

Question 25

Authorization number given to the referred physician

Answer 25

referral number

Question 26

HIPAA Referral Certification and Authorization

Answer 26

HIPAA X12 278 transaction in which a provider asks a health plan for approval of a service and gets a response

Question 27

Document a patient signs to guarantee payment when a referral authorization is pending

Answer 27

referral waiver

Question 28

Health plan that pays benefits first

Answer 28

primary insurance

Question 29

Second payer on a claim

Answer 29

secondary insurance

Question 30

third payer on a claim

Answer 30

tertiary insurance

Question 31

health plan that covers services not normally covered by a primary plan

Answer 31

supplemental insurance

Question 32

Explains how an insurance policy will pay if more than one policy applies

Answer 32

coordination of benefits (COB)

Question 33

Birthday Rule

Answer 33

guideline stating that the parent whose day of birth is earlier in the calendar year is primary

Question 34

Gender Rule

Answer 34

guideline that states when a child is covered by 2 health plans, the father’s plan is primary

Question 35

List of the diagnoses, procedures, and charges for a patient’s visit

Answer 35

encounter form

Question 36

HIPAA Coordination of Benefits

Answer 36

HIPAA X12 837 transaction sent to a secondary or tertiary payer

Question 37

Procedures that ensure billable services are recorded and reported for payment

Answer 37

charge capture

Question 38

TOS payments

Answer 38

Time-of-Service

Question 39

Participating physician’s agreement to accept allowed charge as full payment

Answer 39

accept assignment

Question 40

Patient with no insurance

Answer 40

self-pay patient

Question 41

Payment made during checkout based on an estimate

Answer 41

partial payment

Question 42

Practice’s rule governing payment from patients

Answer 42

financial policy

Question 43

real-time adjudication (RTA)

Answer 43

process used to generate the amount owed by a patient

Question 44

Policy of collecting and retaining patient’s credit card information

Answer 44

credit card on file (CCOF)