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Official Course
Description: MCCCD Approval: 12-13-05 |
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HIM181
2006 Fall – 2009 Summer II |
L+L |
3.0 Credit(s) |
5.0 Period(s) |
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Medical
Claims Processing |
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Application
of third-party payer billing information to claims processing in the
non-hospital setting. Use of the computer for claims submission. Management
of claims to ensure confidentiality, data retention, and successful payment
for services. Prerequisites: [(BPC101AA or
BPC/CIS121AE) and HIM180], or permission of Program Director. Prerequisites or Corequisites:
(HIM185 and HIM212), or permission of Program Director. |
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Go to Competencies Go to Outline
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MCCCD
Official Course Competencies: |
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HIM181 2006
Fall – 2009 Summer II |
Medical Claims Processing |
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1.
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Define selected terms related to computerized billing. (I)
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2.
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Describe prevention measures to ensure computer
confidentiality. (I) |
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3.
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Follow office procedures for manual and electronic claims
processing. (II, III) |
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4.
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Explain the requirements for data retention and storage in
relation to claims processing. (II, III) |
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5.
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Design, modify, and/or update superbills
to reflect health care services. (III) |
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6.
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Explain the claims procedures for the major third-party
payers. (III) |
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7.
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Prepare claims for submission to major third-party payers.
(II-IV) |
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8.
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Develop policies and procedures for managing insurance
claims. (IV) |
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9.
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Prepare supporting documentation as needed for proper
claims processing. (IV) |
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10.
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Verify benefits with third-party payers. (IV) |
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11.
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Describe steps taken to resolve delinquent and/or denied
claims. (IV) |
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12.
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Prepare claims for rebilling. (IV) |
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13.
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Respond to requests for claims review and appeal. (IV) |
Go to Description Go to top of
Competencies
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MCCCD
Official Course Outline: |
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HIM181 2006
Fall – 2009 Summer II |
Medical Claims Processing |
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I. Computer Basics A.
Computer terminology B. Confidentiality II. Electronic Data
Interchange A. Computer claims systems B. Data interchange C. Data storage III. Claims Management A. Superbill/source
documents B. Claims processing and
payment methodologies 1. Managed care systems 2. Commercial insurance
carriers 3. Medicaid and state programs
4. Medicare 5. CHAMPUS, CHAMPVA, and
TRICARE 6. Worker's compensation 7. Disability income and
benefit programs C. Alternative care
providers IV. Reimbursement
Management A. Policies and procedures B. Documentation C. Explanation of benefits D. Problem claims E. Rebilling F. Review and appeal
process |
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