Chapter 3-Patient Encounters and Billing Information

Key Words

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTIES-Patient has read the privacy practices

and understands how the provider intends to protect the patient’s rights to privacy under HIPAA

ASSIGNMENT OF BENEFITS-Patient authorizes payment to go directly to the provider

BIRTHDAY RULE-Parent who’s birthday is first in calendar year and used to determine primary coverage

CERTIFICATION NUMBER-Same as prior authorization #-certifying the admission/procedure

CHART NUMBER-Unique number that identifies the patient

COB-Coordination of benefits-only pays up to 100% of benefits

CO-PAY-Due at the time of service. Amount patient is responsible for when he visits physician, can be collected

before the encounter

DIRECT PROVIDER-Directly treats a patient

ENCOUNTER FORM-May be paper or electronic (superbills)

EOB-Explanation of Benefits

ESTABLISHED PATIENT (EP)-patient seen by provider or group within last 3 years

FINANCIAL POLICY-Practices rules for payment for medical services

GENDER RULE-Child covered under father/mother the father’s insurance is primary

GUARANTOR-Policyholder, person responsible for bill

HIPAA ELIGIBILITY FOR A HEALTH PLAN TRANSACTION-Used to verify patient insurance

HIPAA REFERRAL CERTIFICATION & AUTHORIZATION-Used to verify patient’s insurance coverage when a

referral is required

INDIRECT PROVIDER-Tests patient as instructed by a direct provider

INSURANCE CARD-Just because a patient presents a card, does not mean he has insurance. The card could be

an old card. Very informative-ID #, Group #, Payer name, coverage, co pay, max services, deductible,

prescriptions

INSURED-Policyholder, subscriber

NEW PATIENT (NP)-Patient has not seen a provider or group within the last three years

NON PAR PROVIDER-Non participating provider-pay higher co-pay, higher co-insurance

PAR PROVIDER-Participating provider-in networking provider

PATIENT INFORMATION FORM-Personal information and insurance information

POLICYHOLDER-Guarantor

POST-Enter payments or charges on the patient’s record

PRE-REGISTRATION-Collecting patient information. Begins before the actual appointment

PRIMARY INSURANCE-The patient’s first insurance

PRIOR AUTHORIZATION #-same as certification #

REFERRAL NUMBER #-Given from insurance when one doctor refers patient to another physician

SECONDARY INSURANCE-Patient’s second insurance. Bill after the primary insurance pays

SELF PAY-No insurance, money due at the time of service (encounter)

SUBSCRIBER-Policyholder, Insured, Guarantor

SUPERBILL-Charge slip, routing slip, can be paper or electronic, encounter form

SUPPLEMENTAL INSURANCE-Fill in the gap

TERTIARY INSURANCE-Patient’s third insurance. Bill after primary/secondary insurance pays

TRACE NUMBER-A unique number assigned when eligibility is checked electronically

WALK OUT RECEIPT-summarizes the service, charges and payment a patient has made for the day’s visit