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MED 112
Chapter 3 Terms
| Question | Answer |
|---|---|
| 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 |
| 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 |
| referring physician | The physician who refers the patient to another physician for treatment |
| 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 |
| insured or subscriber | The policyholder of a health plan or medical insurance policy; also known as guarantor |
| guarantor | A person who is financially responsible for the bill from the practice |
| assignment of benefits | Authorization by a policyholder that allows a health plan to pay benefits directly to a provider |
| 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 |
| direct provider | Clinician who treats the patient face-to-face, in contrast to an indirect provider such as a laboratory |
| indirect provider | Clinician who does not interact face-to-face with the patient, such as a laboratory |
| chart number | A unique number that identifies a patient |
| 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 |
| electronic eligibility verification | Required payer response to the HIPAA standard transaction |
| trace number | A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits |
| prior authorization number | Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the certification number |
| certification number | Number returned electronically by a health plan approving a referral authorization request when preauthorization is required |
| referral number | Authorization number given by a referring physician to the referred physician |
| 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 |
| referral waiver | Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending |
| primary insurance (payer) | Health plan that pays benefits first when a patient is covered by more than one plan |
| secondary insurance (payer) | The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan |
| tertiary insurance | The third payer on a claim |
| supplemental insurance | Health plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan |
| 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 |
| 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 |
| gender rule | Coordination of benefits rule for a child insured under both parents’ plans under which the father’s insurance is primary |
| encounter form | A list of the diagnoses, procedures, and charges for a patient’s visit; also called the superbill |
| charge capture | Office procedures that ensure that billable services are recorded and reported for payment |
| accept assignment (acceptance of assignment) | A participating physician’s agreement to accept the allowed charge as payment in full |
| self-pay patient | A patient who does not have insurance coverage |
| 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 |
| financial policy | A practice’s rules governing payment for medical services from patients |
| 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 |
| credit card on file (CCOF) | Policy of collecting and retaining patients’ credit card information |
Created by:
Felicia26