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INSUR {CBCS-CPC}
Patient Encounters and Billing Information
| Term | Definition |
|---|---|
| accept assignment | A participating physician’s agreement to accept the allowed charge as payment in full. |
| acknowledgment of receipt of notice 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. |
| 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. |
| primary insurance | 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 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 | 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. |
| physician or a qualified healthcare professional, such as a physician assistant | provider |
| five types of important new patient information | 1. pre-registration & scheduling info 2. medical history 3. patient or guarantor & insurance data 4. assignment of benefits 5. acknowledgment of receipt of notice of privacy practices |
| these have embedded data that require a pin for access | smart cards |
| under HIPAA providers do not need specific authorization to release which 3 forms of PHI | 1. treatment 2. payment 3. healthcare operations |
| example of an indirect provider | pathologist |
| the amount of time providers must retain signed acknowledgments | six years |
| 3 steps to establish financial responsibility | 1. verify patient eligibility for insurance benefits 2. determine preauthorization & referral requirements 3. determine the primary payer if more than one insurance plan is in effect |
| 3 points of payer verification | 1. patients' 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 |
| requires patients to be notified if their insurance is not going to cover a visit | Medicare |
| government-sponsored plan in which eligibility can change monthly | Medicaid |
| the number 270 | refers to the inquiry that is sent |
| the number 271 | refers to the answer returned by the payer |
| ABN | advance beneficiary notice (Medicare) |
| referral number | Authorization number given by a referring physician to the referred physician. |
| also called the superbill, charge slips, or routing slips | encounter form |
| specially designed encounter forms that are used when the provider sees patients in the hospital | hospital charge tickets |
| must meet large deductibles before the health plan makes a payment | patients with Consumer Driven Health Plans |
| may be required to pay in full at time of service | patients with self-pay coverage |
| under this health plan the provider is NOT permitted to collect the deductible or any other payment until receiving data on how the claim is going to be paid | Medicare |
| (RTA) real-time adjudication process | 1. create the claim while the patient is being checked out 2. transmit the claim to the payer 3. receive an immediate respone from the payer |
| eligibility for benefits for an HMO patient | 1. provider is a plan participant 2. the patient is listed on the plan's enrollment master list 3. the patient is assigned to the PCP as of the date of service |
| another term used for the prior authorization number | certification number |
| referred patient qualifications | 1. verify patient enrollment in plan 2. check that the patient has a referral number 3. understand the restrictions of services |
| Under Medicare, the ABN must be given to the patient and signed | prior to receiving uncovered services |
| union membership | possible additional coverage a patient may have |
| a.k.a.: fill-the-gap insurance | supplemental insurance |
| covers parts of expenses such as coinsurance | supplemental insurance |
| PMP info contained in database of payer | 1. payer's name & contact name 2. health plan type (HMO/PPO) 3. telephone/fax numbers |
| location where payer communications are documented | patient financial record |
| encounter form customizations | date of appointment | patients name | id number assigned by the medical practice | previous balance | day's fees | payments made | amount due |
| up-front collection | money collected before the patient leaves the office |
| signs and dates the completed encounter form | the physician |
| encounter form distribution | medical record | financial record | to the patient |
| files claims for Medicare patients as a courtesy | nonparticipating providers |
| up-front collection process | claim is created and sent to payer | practice waits to receive ins payment | post payment amount in patient's account in PMP | patient is billed for the balance |
| excluded services | noncovered services |
| financial policy items explanations | unassigned claims | assigned claims | copayments |
| areas where practice's financial policy should be displayed | wall of reception area | new patient info packet |
| RTA | real-time adjudication |
| (CCOF) credit card on file authorizes | payment for outstanding balances |
| (CCOF) credit card on file process must be compliance with | HIPAA regulations |
| the result of referral and authorization | a certification number for a procedure |
Created by:
VA_MedCod3r