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