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Chapter 3 Patient encounters and billing information
Terms in this set (62)
participating physician's agreement to accept allowed charge as full payment
What does the abbreviation EP mean?
established patient: patient seen provider within the past 3 years.
Acknowledgment of Receipt of Notice of Privacy Practices
form accompanying a covered entity's Notice of Privacy Practices.
assignment of benefits
authorization allowing benefits to be paid directly to a provider.
guideline that determines which patient has the primary insurance for a child.
movement of monies into or out of a business
identifying code assigned when preauthorization is required.
procedures that ensure billable services are recorded and reported for payment.
coordination of benefits (COB)
explains how an insurance policy will pay if more than one policy applies
clinician who treats a patient face-to-face.
list of the diagnoses, procedures, and charges for a patient's visit.
established patient (EP)
patient who has seen a provider within the past 3 years.
practice's rules governing payment from patients.
coordination of benefits rule for a child insured under both parents plans.
person who is not financially responsible for the bill.
HIPAA Coordination of Benefits
HIPP X12 8378 transaction sent to a secondary or tertiary payer.
HIPAA Eligibility for a Health Plan
HIPAA x12 270/271 transaction in which a provider asks for and receives an answer about a patient's eligibility for benefits.
HIPAA Referral Certification and Authorization
HIPAA X12 278 transaction in which provider asks a health plan for approval of a service and gets a response.
clinician who does not interact face-to-face with a patient.
Define the abbreviation (PAR)
participating provider: provider agrees medical services to payers policy holders according to contract.
policyholder or subscriber to a health plan or policy
What does the abbreviation NP mean?
new patient: patient who has not seen a provider within the past 3 years.
nonparticipating provider (nonPAR)
provider who does not join a particular health plan.
payment made during checkout based on an estimate
participating provider (PAR)
provider who agrees to provide medical services to a payer's policy holders according to a contract.
patient information form
form that includes a patient's personal, employment, and insurance company data.
health plan that pays benefit first
prior authorization number
identifying code assigned when preauthorization required.
real-time claims adjudication (RTCA)
process used to generate the amount owed by a patient.
authorization number given to the referred physician.
document a patient signs to guarantee payment when a referral authorization is pending.
Physician who transfers care of a patient to another physician.
second payer on a claim
patient with no insurance
health plan that covers services not normally covered by a primary plan.
third payer on a claim
Define the abbreviation COB?
coordination of benefits:explain how insurance policy will pay if more than 1 policy applies.
number assigned to a HIPAA 270 electronic transaction
Explain the method used to classify patients as new or established.
* New patients are those who have not received any services from the provider within the past 3 years.
* established patients have seen the provider within the past 3 years.
* established patients review and update the information that is on file about them.
Discuss 5 categories of information required of new patients
1. basic personal preregistration and scheduling information
2. the patient's detailed medical history
3. insurance data for the patient or guarantor
4. a signed and dated assignment of benefits statement by the policy holder.
5. a signed Acknowledgement of Receipt of Notice of Privacy Practices authorizing the practice to release the patient's PHI for TPO purposes.
Explain how information for established patients is updated.
*patient information form are reviewed at least once per year by established patients.
*Patients are often asked to double-check their information at their encounters.
* PMP is updated to reflect any changes as needed, and the provider strives good communication with the patient to provide the best possible service.
verify patients eligibility for insurance benefits
to verify patients eligibility the provider:
* check the patient information form and ;medical insurance card (except in medical emergency situations)
*contracts the payer to verify the patient's general eligibility for benefits and the amount of co payment or coinsurance that is due at the encounter, and to determine whether the planned encounter is for a covered service that is considered medically necessary by the payer.
Define abbreviation "COB"
coordination of benefits: explain how insurance policy will pay if more than 1 policy applies.
Discuss the importance of requesting referral or preauthorization approval
* preauthorization is requested before a patient is given certain types of medical care.
*in case of referrals, the provider often needs to issue a referral number and a referral document in order for the patient to see a specialist under the terms of medical insurance.
* providers must handle these situations correctly to ensure that the services are covered if possible.
Determine primary insurance for patients who have more than one health plan.
* patient information forms and insurance cards are examined to determine whether more than one health insurance policy is in effect.
* if so the provider determines which policy is the primary insurance based on coordination of benefits rules.
*this information is then entered into the PMP and all necessary communications with the payers are performed.
Summarize the use of encounter forms?
*encounter forms are lists of a medical practice's most commonly performed services and procedures and often its frequent diagnoses.
* provider checks off services and procedures a patient received, and the encounter forms is then used for billing.
Identify the 8 types of charges that may be collected from patients at the time of service.
* Practices routinely collect up-front money from patients at this time of their office visit as an important source of cash flow.
1. previous balance
4. noncovered or overlimit fees
Charges or nonparticipating provider
Explain the use of real time claims adjudication tools in calculating time-of-service payments.
Real time adjudication tools:
* allow the practice to view, at the time of service, what the health plan will pay for the visit and what the patient will see.
* provide valuable information and checks so that the practice and patients are aware of the expected costs and coverage
* inform or remind patients of the financial policy and give estimates of the bills they will owe.
A patient's group insurance number written on the patient information or update form must match?
The number on the patients insurance card
If a health plan member receives medical services from a provider who does not participate in the plan the cost the the member is?
What information does a patient information form gather?
The patients personal information, employment data, and insurance information.
If a husband has an insurance policy but is also eligible for benefits as a dependent under his wife's insurance policy; the wife's policy is considered ___ for him.
A certification number for a procedure is the result of which transaction and process?
referral and authorization
A practice's rules for payment for medical services are found in their?
The encounter form is a source of ______ in information for the medical specialist.
Under Medicare, what must a provider receive before it is permitted to collect a deductible or any other payment?
authority to accept the assignment
Which charges are usually collected at the time of service?
Copayments, non covered or over limit fees, charges of nonparticipating providers, and charges for self pay patients
The tertiary insurance pays?
After the first and second payers
Define the abbreviation? nonPAR
nonparticipating provider: provider who does not join particular health plan.
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