Patient Encounters and Billing Information

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Questions and Answers

What is a New Patient?

A group of providers in a managed care organization

A physician who transfers care of a patient to another physician

A patient who has seen a provider within the past three years

Someone who has not received any services from the provider in the past three years (correct)

What characterizes an Established Patient?

Provider who agrees to provide medical services to a payer

Patient who has seen a provider within the past three years (correct)

Someone who has not seen a provider in the past three years

Provider that does not have a participation agreement with a plan

Who is a Referring Physician?

A physician who transfers care of a patient to another physician.

What is meant by the term 'Network'?

A group of providers in a managed care organization. Signup and view all the answers

What is a Participating Provider (PAR)?

A provider who agrees to provide medical services to a payer's policyholders according to a contract. Signup and view all the answers

Define a Nonparticipating Provider (nonPAR).

A provider who does not join a particular health plan. Signup and view all the answers

What does Out-of-Network refer to?

A provider that does not have a participation agreement with a plan. Signup and view all the answers

What is included in a Patient Information Form?

A patient's personal, employment, and insurance company data. Signup and view all the answers

What does Insured refer to?

The policyholder or subscriber to a health plan or policy. Signup and view all the answers

Who is referred to as the Subscriber?

The insured. Signup and view all the answers

What is the role of a Guarantor?

The person who is the insurance policyholder for a patient and is financially responsible for the bill. Signup and view all the answers

Define Social History in medical terms.

Covers lifestyle factors such as smoking, exercise, and alcohol use. Signup and view all the answers

What do Medical History Forms ask for?

Information about the patient's personal medical history, the family's medical history, and social history. Signup and view all the answers

What is a Policyholder?

The holder of the insurance policy that covers the patient. Signup and view all the answers

What are Insurance Cards used for?

To verify the patient’s coverage and ensure accuracy of information. Signup and view all the answers

What does Assignment of Benefits mean?

Authorization allowing benefits to be paid directly to a provider. Signup and view all the answers

What is the purpose of an Acknowledgment of Receipt of Notice of Privacy Practices?

To ensure patients are informed about their privacy rights. Signup and view all the answers

What is a Chart Number?

A unique number that identifies a patient. Signup and view all the answers

What is a Practice Management Program (PMP)?

A database of patients and payers used within a medical office. Signup and view all the answers

The steps for Patient Eligibility for Insurance Benefits include verifying eligibility, determining preauthorization and referral requirements, and ___?

determining the primary payer. Signup and view all the answers

What requires contacting the payer for verification?

Verifying the patient's general eligibility for benefits Signup and view all the answers

A Medical Emergency implies care is provided only after checking insurance.

False Signup and view all the answers

What are Factors Affecting Insurance Eligibility?

If premiums are required, patients must have paid them on time. Signup and view all the answers

Study Notes

Patient Definitions

New Patient: A person who has not received services from the provider or a similar specialty within the last three years.
Established Patient: A patient who has seen the provider in the past three years.

Healthcare Providers

Referring Physician: A doctor who transfers a patient's care to another physician.
Participating Provider (PAR): A provider who agrees to deliver services to patients covered by a specific health plan under a contract.
Nonparticipating Provider (nonPAR): A provider who does not join a specific health insurance plan.
Out-of-Network Provider: A provider without a participation agreement with a health plan; patients without out-of-network benefits are fully responsible for costs.

Patient Information

Patient Information Form: A form detailing personal, employment, and insurance data of patients.
Insured: A person who holds a policy under a health plan.
Subscriber: The individual who is insured under a health policy.
Guarantor: The insurance policyholder accountable for the patient's medical expenses.

Patient History and Socioeconomic Factors

Social History: Information regarding lifestyle choices, including smoking, exercise, and alcohol consumption.
Medical History Forms: Forms that collect details on the patient's personal and family medical history, along with social history.

Insurance and Billing

Policyholder: The individual who owns the insurance policy; this can be a patient or someone not receiving care from the practice.
Insurance Cards: Essential documents that need to be accurately processed during patient registration to match information during claims.
Assignment of Benefits: A directive for insurance benefits to be paid directly to a healthcare provider.

Privacy and Legal Forms

Acknowledgment of Receipt of Notice of Privacy Practices: A form that indicates the patient has received privacy information; only direct care providers need a signed acknowledgment.

Administrative Processes

Chart Number: A unique identifier for patients linking all related medical information.
Practice Management Program (PMP): A database that tracks patients, insurers, and visits, requiring continuous updates.
Patient Eligibility for Insurance Benefits: The process of determining a patient's financial responsibility includes verifying coverage, preauthorization needs, and identifying the primary insurer.

Verification and Emergencies

Contacting the Payer for Verification: A procedure to confirm a patient's eligibility, required payments, and covered services for an encounter.
Medical Emergency: Immediate care provided, with insurance status verified post-encounter.

Insurance Eligibility Considerations

Factors Affecting Insurance Eligibility: Timely premium payments are necessary to maintain coverage, especially for government-sponsored plans.

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Description

This quiz focuses on key terms related to patient encounters and billing information, providing definitions for essential healthcare concepts. Understand the difference between new and established patients, as well as the role of a referring physician. Perfect for students in healthcare administration or medical billing courses.