The game is played with a standard 52-card deck and a joker that serves as a wild card in straights, flushes and straight flushes. The joker may also be used as an ace in any hand, and in some casinos may be considered completely wild. The dealer shuffles the deck and deals out seven stacks of seven cards, discarding the remaining four cards. All bets are made and then the dealer shakes and rolls three dice from a teacup to determine which player will get the first stack of cards. The dealer totals the amount shown in the dice, and then starting with himself, counts around the players at the table in a clockwise motion until he reaches the player who gets the first hand. The remaining hands are dealt out to the players in a counterclockwise motion.

When the players receive their cards, they set them into two hands of five and two cards. The two-card hand is known as the low hand is placed in front of the five-card hand known as the high hand. Each five-card hand is ranked according to the pai gow poker hierarchy which varies only slightly from the standard poker hand hierarchy. The only real difference is that five aces, which are accomplished by adding four aces to a joker, beats out a royal flush and is the highest hand in the game.

The hierarchy of two-card hands is much simpler in that the hand is either a pair or it is not. The highest two-card hand is a pair of aces, and the rank of subsequent pairs falls in order from kings down to two's. The same ranking order applies to single cards.

It is the players' responsibility to ensure that their five-card hand has a higher ranking then their two-card hand. If the two-card hand turns out to be higher, the hand is said to be foul and the player automatically loses his bet.

When all the player's cards have been set, the banker's cards are turned face up by the dealer. It is then the banker's job (not the dealer's) to arrange the stack into a two-card hand and a five-card hand. The banker's hands are then individually compared to the players' hands in a clockwise order, starting with the player who received the cards first.

To win, both of the player's hands must beat both of the banker' hands. If the player's two-card hand and the banker's two-card hand have equal poker value, they are said to be copies. The same applies if the five-card hands match in value as well. The banker wins all copies. If one of the player's hands beats the banker's, but the other does not, the result is a tie and no money changes hands.

When a player wins, the dealer uses the banker's money to pay the player even money for their bet. If the player's hand loses, the dealer awards the player's bet to the banker. The house makes its money by taking a 5% commission on each winning bet. The dealer collects the commission from each player that wins a hand, and from the total of the banker's winnings.