Maricopa Community Colleges  GBS255   19946-20086 
Official Course Description: MCCCD Approval: 07/22/08
GBS255 19946-20086 L+L 2 Credit(s) 4 Period(s)
Automated Claims Processing
Claims processing on the computer. Emphasis on file maintenance, entering claims, and resolving claims.
Prerequisites: GBS253.
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MCCCD Official Course Competencies:
 
GBS255   19946-20086 Automated Claims Processing
1. Explain how to use the computer system to process medical claims. (I - IV)
2. Correct system processing errors. (I)
3. Identify and describe various computer screens used to process health insurance claims. (I)
4. Maintain the medical provider and member address file. (II)
5. Resolve claims with missing or incorrect provider and/or member information. (II)
6. Update provider records with provider review and Preferred Provider Organization (PPO) network information. (II)
7. Describe workflow regarding mail, referrals and documentation. (III)
8. Enter health insurance claims information on the computer system. (III)
9. Resolve various types of health insurance claims on the computer. (IV)
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MCCCD Official Course Outline:
 
GBS255   19946-20086 Automated Claims Processing
    I. Computer Claims Overview
        A. Computer Application
        B. System Interactions
        C. System Logic
        D. Screen Descriptions
        E. System Processing Errors
      II. File Maintenance
          A. Provider
            1. Adding
            2. Changing
            3. Deleting
          B. Member
            1. Adding
            2. Address Change
          C. PPO Network
            1. Adding
            2. Changing
            3. Canceling
        III. Entering Claims Information
            A. Workflow
              1. Mail
              2. Referrals
              3. Documentation
            B. Professional Charges
              1. Physician
              2. Drug
              3. Anesthesia
              4. Chiropractic
              5. Durable Medical Equipment
              6. Surgery
              7. Lab
              8. Therapy
            C. Facility
              1. Inpatient
              2. Outpatient
              3. Surgical Center
              4. Birthing Center
              5. Rehabilitation
              6. Skilled Nursing
            D. Pre-Certification
          IV. Resolving Claims
              A. Certificate Application
              B. Message Processing
              C. Claims Bulletins
              D. On-Line Help
              E. Missing Information
              F. Correspondence
              G. Investigation
              H. PPO
              I. Specialty Claims
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