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MODULE VII
Reviewing Healthcare Claims
Paula Tripp, CMAA, CBCS, CET, CPT, CHI, RHE - E-mail
This is a 5 week course!
Course Description:
This course concentrates on the terms and expressions commonly used in the industry. It also introduces you to the various types of payer systems, protocol and procedures used by health care payers.
The course has a broad perspective for health insurance reviewers and examiners introducing common responsibilities such as customer service, claims processing, coordination of benefits, prior authorization, utilization review, and others.
This course will also discuss legal topics such as HIPAA, fraud and abuse, insurance claims regulation and other administrative topics.
Recommended Pre-Requisites:
It is recommended that students complete Modules I-V, or possess educational and/or experience equivalence to; before taking this module.
Course Objectives:
Upon successful completion of this course, students will possess a basic understanding of:
- The costs leading to insurance policies and application to insurance companies
- The career and choices within the field
- Health insurance terms. Examples include underwriting, adverse selection, risk pool, pre-existing condition
- Standard policy provisions are described and defined
- Specific steps and common protocols of payers
- Types of denials, reviews and appeals
- Managing and reporting mechanisms and methodologies
- Basic legal issues such as HIPAA, fraud and abuse and other applicable topics
It is necessary to complete all lessons, assignments and tests in this course. There is a Midterm and a Final. You may choose to Email your completed assignments to me at mapaula@canyoncollege.edu.
Grading:
Students must successfully complete all assignments and tests. (Refer to Program Syllabus for Percentage Point/Grade Ranges.)
Reviewing Healthcare ClaimsCourse Outline:
Assignments 1,2,3,5 - 50 points ea. Assignment 4 - 100 points Midterm - 100 points Final - 100 points Total - 500 points
| LESSON 1 | Introduction to Claims Reviewing The career and health insurance within the field Terms and Definitions |
| LESSON 2 | Departments within an Insurance Company Departments Other considerations of payers |
| LESSON 3 | Claims Reviewers Duties and responsibilities Workflow and steps within in the process |
| MIDTERM | |
| LESSON 4 | Claim Denials and Appeals Billing errors and protocol Types of reviews and appeals |
| LESSON 5 | Reports and Management Managing claims Reports and reporting mechanisms |
| FINAL EXAM | |
Disclaimer:
This course is designed for educational purposes and to be a guide for health claims examining and reviewing. Information within the course is based on research, experience and current guidelines; however, due to the complex and changing environment in the field, it is recommended to keep current as details can change. Health claims examining and reviewing decisions should be based on legal/ethical considerations, payer policies and federal/state guidelines.
General References:
- Claims Adjusters, Appraisers, Examiners, and Investigators, Bureau of Labor Statistics, U. S. Department of Labor, Occupational Outlook Handbook, 2006-07 Edition. http://www.bls.gov/oco/ocos125.htm. December 20, 2005.
- Review of Insurance Transactions Directly Affecting Consumers which Involve Use of Third Party Vendors National Association of Insurance of Insurance Commissioners, June 2004: http://www.naic.org/legal/ and American Association of Independent Claims Professionals http://www.aaicp.net/.
- Regulations and Guidance Centers for Medicare and Medicaid (CMS). http://www.cms.hhs.gov/home/regsguidance.asp 12/2005.
- A Guide to Health Insurance Billing by Marie A. Moisio. Delmar Thomson Learning Publishers. 2004.
- Health Professionals and News. Blue Cross Blue Shield Association http://www.bcbs.com/healthprofessionals/index.html. 2004/2005.
- Terms you should know, Lucent Technologies Inc. Medical Expense Plan for Active Management Employees http://216.220.43.231/mgt/library/mep/content.asp. 6/2002.