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Billing and Coding
Chapter 3 Terms
| Term | Definition |
|---|---|
| Accept Assignment | A participating physician’s agreement to accept the allowed charge as payment in full. |
| Acknowledgment of Receipt of Notices of Privacy Practices | Form accompanying a covered entity’s Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgment. |
| Assignment of Benefits | Authorization by a policyholder that allows a health plan to pay benefits directly to a provider. |
| Birthday rule | The guideline that determines which of two parents with medical coverage has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary. |
| Certification Number | Number returned electronically by a health plan approving a referral authorization request when preauthorization is required. |
| Charge Capture | Office procedures that ensure that billable services are recorded and reported for payment. |
| Chart Number | A unique number that identifies a patient. |
| Coordination of Benefits (COB) | A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim. |
| Credit Card on File (CCOF) | Policy of collecting and retaining patients’ credit card information. |
| Direct Provider | Clinician who treats the patient face-to-face, in contrast to an indirect provider such as a laboratory. |
| Electronic Eligibility Verification | Required payer response to the HIPAA standard transaction. |
| Encounter Form | A list of the diagnoses, procedures, and charges for a patient’s visit; also called the superbill. |
| Established Patient (EP) | Patient who has received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years. |
| Financial Policy | A practice’s rules governing payment for medical services from patients. |
| Gender Rule | Coordination of benefits rule for a child insured under both parents’ plans under which the father’s insurance is primary. |
| Guarantor | A person who is financially responsible for the bill from the practice. |
| HIPAA Coordination of Benefits | The HIPAA ASCX12N 837 transaction that is sent to a secondary or tertiary payer on a claim with the primary payer’s remittance advice. |
| HIPAA Eligibility for a Health Plan | The HIPAA X12N 270/217 transaction in which a provider asks a health plan for information on a patient’s eligibility for benefits and receives an answer from the plan. |
| HIPAA Referral Certification and Authorization | The HIPAA X12N 278 transaction in which a provider asks a health plan for approval of a service and the health plan responds, providing a certification number for an approved request. |
| Indirect Provider | Clinician who does not interact face-to-face with the patient, such as a laboratory. |
| Insured/Subscriber | The policyholder of a health plan or medical insurance policy; also known as guarantor. |
| New Patient (NP) | A patient who has not received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years. |
| Nonparticipating provider (nonPAR) | A provider who chooses not to join a particular government or other health plan. |
| Partial Payment | An amount a medical practice may ask the patient to pay at the time of service that represents a percentage of the total estimated amount due for the current services received. |
| Participating Provider (PAR) | A provider who agrees to provide medical services to a payer’s policyholders according to the terms of the plan’s contract. |
| Patient Information Form | Form that includes a patient’s personal, employment, and insurance company data needed to complete a healthcare claim; also known as a registration form. |
| Portal | Website that serves as an entry point to other websites |
| Primary Insurance (payer) | Health plan that pays benefits first when a patient is covered by more than one plan. |
| Prior Authorization Number | Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the certification number. |
| Real-time Adjudication (RTA) | Electronic health insurance claim processed at patient check-out; allows practice to know what the patient will owe for the visit. |
| Referral Number | Authorization number given by a referring physician to the referred physician. |
| Referral Waiver | Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending. |
| Referring Physician | The physician who refers the patient to another physician for treatment. |
| Secondary Insurance (payer) | The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan. |
| Self-Pay Patient | A patient who does not have insurance coverage. |
| Supplemental Insurance | Health plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan. |
| Tertiary Insurance | The third payer on a claim. |
| Trace Number | A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits. |
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