Understananding Health Insurance

When a provider's office contacts the payer to verify a patient's insurance eligibility and benefit status, HIPAA privacy standards mandate that four areas of pertinent information be provided. Name them.

1. Last name and first initial 2. Date of birth 3. Health insurance claim number 4. Gender

List some examples of covered entities.

1. Private sector health plans 2. Managed care organizations 3. ERISA-covered health benefit plans 4. Government health plans 5. Healthcare clearinghouses 6. Providers that submit or receive transactions electronically

What does the claims adjudication process verify?

1. Required information is available to process the claim. 2. The claim is not a duplicate. 3. Payer rules and procedures have been followed. 4. Procedures performed or services provided are covered benefits.

What is the purpose of the new patient interview and check-in procedure?

1. To obtain pertinent information 2. To schedule an appointment 3. To generate a patient record 4. To explain office policies and procedures

What is a claims attachment?

A claims attachment is a set of supporting documentation or information that is associated with a healthcare claim or patient encounter.

What is a clearinghouse?

A clearinghouse is a public or private entity that processes or facilitates the processing of nonstandard data elements (e.g., paper claims) into standard data elements (e.g., electronic claims).

Define a day sheet

A day sheet is a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.

Explain allowed charges.

Allowed charges are the maximum amount the payer will allow for each procedure or service, according to the patient's policy.

Explain primary insurance versus secondary insurance.

Primary insurance is the insurance plan that is responsible for paying healthcare insurance claims first. A secondary insurance plan is billed for the remainder of the balance due.

Define encounter form, and distinguish between a superbill and a chargemaster.

The encounter form is the financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. It is also called a superbill. A chargemaster is an encounter form generated in the hospital setting.

What is the gender rule?

The gender rule states that the father's plan is always primary when a child is covered by both parents.

What is the patient ledger?

The patient ledger is a permanent record of all financial transactions between the patient and the practice.

Explain the difference between assignment of benefits and accept assignment.

To accept assignment means that the provider agrees to accept what the insurance company allows or approves as payment in full for the claim. Assignment of benefits means the patient and/or insured authorizes the payer to reimburse the provider directly.