|
Official Course
Description: MCCCD Approval:
5-26-2009 |
||
|
HIM181 2009 Fall – 2011 Fall |
L+L
3.0 Credit(s) 5.0 Period(s) 4.4 Load Occ |
|
|
Medical
Claims Processing |
||
|
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: (BPC110, HIM180, and
HIM209), or permission of Program Director. Prerequisites or Corequisites: HIM214 or permission of Program
Director. |
||
Go to Competencies Go to Outline
|
MCCCD
Official Course Competencies: |
|
|
|
|
|
HIM181 2009
Fall – 2011 Fall |
Medical Claims Processing |
|
1.
|
Define selected terms related to computerized billing. (I)
|
|
2.
|
Describe prevention measures to ensure computer
confidentiality. (I) |
|
3.
|
Follow office procedures for manual and electronic claims processing.
(II, III) |
|
4.
|
Explain the requirements for data retention and storage in
relation to claims processing. (II, III) |
|
5.
|
Design, modify, and/or update superbills
to reflect health care services. (III) |
|
6.
|
Explain the claims procedures for the major third-party
payers. (III) |
|
7.
|
Prepare claims for submission to major third-party payers.
(II-IV) |
|
8.
|
Develop policies and procedures for managing insurance
claims. (IV) |
|
9.
|
Prepare supporting documentation as needed for proper
claims processing. (IV) |
|
10.
|
Verify benefits with third-party payers. (IV) |
|
11.
|
Describe steps taken to resolve delinquent and/or denied
claims. (IV) |
|
12.
|
Prepare claims for rebilling. (IV) |
|
13. 14.
|
Respond to requests for claims review and appeal. (IV) Describe the process used to gather data for and the
content of common end of month and audit reports. (IV) |
Go to Description Go to top of
Competencies
|
MCCCD
Official Course Outline: |
|
|
|
|
|
HIM181 2009
Fall – 2011 Fall |
Medical Claims Processing |
|
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. Series billing D. Explanation of benefits E. Problem claims F. Rebilling G. Review and appeal
process H. End of month reports I. Audits |
|