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Chapter 3: Patient Encounters and Billing Information
Terms in this set (30)
Acknowledgement 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 acknowledgement.
assignment of benefits
Authorization by a policyholder that allows a health plan to pay for benefits directly to a provider
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.
Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the prior authorizaiton number.
Office procedures that ensure that billable services are recorded and reported for payment
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
A list of the diagnoses, procedures, and charges for a patinet'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.
Coordination of benefits rule for a child insured under both parents' plans under which the father's insurance is primary.
A person who is the insurance policyholder for a patient of 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 transaciton 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.
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.
The policyholder or subscriber to a health plan or medical insurance policy; also known as a guarantor.
A group of providers in a managed care organization that allows patients to avoid paying higher charges.
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.
A provider that does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan's enrollees.
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 health care claim; also known as a registration form.
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.
Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending.
The physician who refers the patient to another physician for treatment.
The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan.
Insurance plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan.
The third payer on a claim.
A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits.
This set is often in folders with...
Chapter 4: Diagnostic Coding
Chapter 5: Procedural Coding
Medicare and Medicaid
Ch.4 - Insurance in the Medical Office
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