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 Module 1 Health Insurance Specialist - Roles and Responsibilities
Objectives - Upon successful completion of this chapter, you should be able to:
Module 2 Introduction to Health Insurance1. Define key terms. 2. Explain the reasons for increasing employment opportunities for health information specialists. 3. Prepare a list of career opportunities for health information specialists. 4. List and discuss the basic skill requirements for aspiring health information specialists. 5. Describe the responsibilities of health information specialists. 6. Name three professional organizations dedicated to working with health information specialists and identify professional credentials for each. Covered Topics Health Insurance Overview Basic Skill Requirements Health Insurance Specialists Responsibilities Professional Credentials
Objectives - Upon successful completion of this chapter, you should be able to:
Module 3 Managed Health Care1. Define key terms. 2. State the difference between medical care and health care. 3. Differentiate between disability and liability insurance. 4. Discuss the history of health care reimbursement from 1860 to the present. 5. Identify and explain the impact of significant events in the history of health care reimbursement. 6. Interpret health insurance coverage statistics. Covered Topics What is Health Insurance? Disability and Liability Insurance Major Developments in Health Insurance Health Insurance Coverage Statistics
Objectives - Upon successful completion of this chapter, you should be able to:
Module 4 Life Cycle of an Insurance Claim1. Define key terms. 2. Compare managed care with traditional health care insurance. 3. Discuss the history of managed care in the United States. 4. List managed health care federal legislation according to year, and provide legislative summaries of each. 5. Delineate the role of a managed care organization. 6. Apply the concept of capitation, as it is associated with managed care. 7. Interpret a manage care profile map that details HMO penetration rates. 8. Explain the role of a gatekeeper in managed care. 9. Identify and explain activities conducted by managed care organizations or their representative organizations (e.g., third-party administrators). 10. Describe six managed care models and provide details about each. 11. Differentiate between the two organizations that accredit managed care organizations. 12. Implement administrative procedures so that the physician's practice appropriately responds to managed care organization program activities. Covered Topics History of Managed Health Care Managed Care Organizations Six Managed Care Models Accreditation of Managed Care Organizations Effects of Managed Care of a Physician's Practice Objectives - Upon successful completion of this chapter, you should be able to:
Module 5 Legal and Regulatory Considerations1. Define key terms. 2. Conduct a new patient interview. 3. Discuss the life cycle of an insurance claim. 4. Determine insurance coverage when a patient has more that one policy or a child covered by both parents. 5. Explain how to process an established patient return visit insurance claim. 6. Perform post clinical checkout procedures. 7. Differentiate between manual and electronic claims processing procedures. 8. Detail the processing of a claim by an insurance company. 9. Interpret information on an explanation of benefits form. 10. Maintain a medical practice's insurance claim files. 11. Identify problems that result in delinquent claims and resolve those problems. Covered Topics Development of the Claim New Patient Interview and Check-in Procedure Established Patient Return Visit Post-Clinical Checkout Procedures Insurance Company Processing of a Claim Maintaining Insurance Claim Files Delinquent Claims Objectives - Upon successful completion of this chapter, you should be able to:
Module 6 ICD-9 Coding1. Define key terms. 2. Provide examples of a statute, regulation and case law. 3. Explain the use of the Federal Register. 4. Discuss ways the insurance specialist can obtain information about new laws and regulations. 5. Give examples of breaches of confidentiality. 6. State the importance of obtaining the patient's signature for the "Authorization for Release of Information" statement on the CMS-1500 claim. 7. Identify two classifications of patients who are not required to sign the "Authorization for Release of Information" statement on the CMS-1500 claim. 8. Explain how the patient authorization for release of information is obtained for electronic claims. 9. Verify a legitimate telephone request for patient information. 10. Process facsimile (fax) requests for patient information. 11. Prepare a confidentiality notice to serve as the first page of faxed patient information. 12. Establish a patient record retention policy for the physician's office. 13. Summarize the CMS Internet Security Policy and the Stark II regulations. 14. List the components of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and explain the health care impact of each. 15. Outline the elements of the Compliance Program Guidance for Physician Practices and the Payment Error Prevention Program. 16. Implement CMS's National Correct Coding Initiative (CCI). 17. Provide and example of unbundling. 18. Differentiate among the NPI, PlanID, EIN, and patient identifier. 19. List the scheduled implementation dates for CMS's electronic health care standards and privacy standards. 20. Explain how overpayments are recovered. Covered Topics Introduction to Legal and Regulatory Considerations Confidentiality of Patient Information Claims Information Telephone Inquiries Facsimile Transmission Confidentiality and the Internet Retention of patient Information and Health Insurance Records Employee Retirement Income Security Act (ERISA) Medical Necessity Federal False Claims Act Health Insurance Portability and Accountability Act of 1996 (HIPAA) Objectives - Upon successful completion of this chapter, you should be able to:
Module 7 CPT Coding1. Define key terms 2. Discuss the difference between "primary diagnosis" and "principal diagnosis". 3. Explain the purpose of reporting diagnosis codes on insurance claims. 4. List and apply CMS guidelines in coding diagnoses. 5. Identify and properly use ICD-9-CM's special terms, marks, abbreviations and symbols. 6. Accurately code all diagnoses according to ICD-9-CM. Covered Topics Introduction to ICD-9-CM Outpatient Coding Guidelines Primary and Principal Diagnoses Principal versus Secondary Procedures Coding Qualified Diagnoses ICD-9-CM Coding System ICD-9-CM Index to Diseases Basis Steps for Using the Index to Diseases ICD-9-CM Tabular List of Diseases Index to Procedures and Tabular List of Procedures ICD-9-CM Index to Disease Tables Supplementary Classifications Coding Special Disorders Considerations to Ensure Accurate ICD-9-CM Coding ICD-10-CM: Diagnostic Coding for the Future Objectives - Upon successful completion of this chapter, you should be able to:
Module 8 HCPCS Coding System1. Define key terms. 2. Discuss the importance of carefully proofreading all code numbers reported on a claim. 3. Explain the format of CPT. 4. Compare ICD-9-CM to CPT. 5. Explain why modifiers were developed for CPT. 6. Determine the level of evaluation and management service. 7. Differentiate between a new and an established patient. 8. List requirements for assigning emergency department and critical care codes. 9. Explain the difference between a consultation and a confirmatory consultation. 10. Discuss qualifications for a "preventive medicine visit". 11. Define "global surgical period" as used in CPT and as applied the insurance industry. 12. Explain the significance of the asterisk next to a CPT code (starred procedure). Covered Topics CPT Coding System CPT Categories, Subcategories and Headings CPT Index CPT Modifiers Basic Steps for Coding Procedures and Services Surgery Section Coding Special Surgery Cases Medicine Section Radiology Section Pathology / Laboratory Section Evaluation and Management Section Evaluation and Management Categories Objectives - Upon successful completion of this chapter, you should be able to:
Module 9 CMS Reimbursement Issues1. Define key terms 2. Describe the three HCPCS levels. 3. State the characteristics of the HCPCS level II coding system. 4. Differentiate types of HCPCS level II codes. 5. Assign HCPCS level II codes and modifiers. 6. Identify claims to be submitted to DMERC, LMC or both, according the MCPCS level II code number. 7. Clarify situations in which both HCPCS level I and II codes are assigned. Covered Topics HCPCS Coding System HCPCS Level II Codes Determining Carrier Responsibility Assigning HCPCS Level II Codes Objectives - Upon successful completion of this chapter, you should be able to:
Module 10 Coding for Medical Necessity1. Define key terms. 2. Explain the historical development of CMS reimbursement systems. 3. List and define each CMS payment system. 4. Apply special rules for the Medicare physician fee schedule payment system. Covered Topics Historical Perspective of CMS Reimbursement Systems CMS Payment Systems Ambulance Fee Schedule Ambulatory Surgical Centers (ASC) Clinical Lab Diagnostic Fee Schedule Durable Medical Equipment, Prosthetics / Orthotics and Supplies Fee Schedule Home Health Prospective Payment System Hospital Inpatient Prospective payment System Inpatient Rehabilitation Facility Prospective Payment System Long-term Care Hospitals Prospective Payment System Skilled Nursing Facility (SNF) Prospective payment System Medicare Physician Fee Schedule Anesthesia, pathology / laboratory and Radiology Services Objectives - Upon successful completion of this chapter, you should be able to:
Module 11 Essential CMS-1500 Claim Instructions1. Define key terms. 2. Select and code diagnoses and procedures from case studies and sample records. Covered Topics Applying Coding Guidelines CPT / HCPCS Billing Considerations Coding from Case Scenarios Coding from Clinic Notes and Diagnostic Test Results Coding Operative Reports Objectives - Upon successful completion of this chapter, you should be able to:
Module 12 Filing Commercial Claims1. Define key terms. 2. Discuss billing guidelines for the following cases: inpatient medical, inpatient/outpatient global surgery, medical/surgical and minor surgery. 3. Apply optical scanning guidelines when completing claims. 4. Discuss reporting guidelines and restrictions covering the following claim items: accept assignment, assignment of benefits, diagnoses, data entry, procedures, modifiers, charges, diagnostic reference numbers and units (on Line 24 of the CMS-1500 claim). 5. Explain why the billing entity's employer tax identification number (EIN) should appear on the claim rather than the provider's Social Security Number. 6. State the processing steps that must occur before a completed claim can be submitted to the payer. 7. Create a "tickler" filing system for completed claims. Covered Topics General Billing Guidelines Optical Scanning Guidelines Assignment of benefits / Accept Assignment Reporting Diagnoses: ICD-9-CM Codes Reporting Procedures and Services: HCPCS National Standard Employer Identifier Number Reporting the Billing Entity Processing Secondary Claims Common Errors That Delay Processing Final Steps in Processing Paper Claims Maintaining Insurance Claim Files for the Practice Objectives - Upon successful completion of this chapter, you should be able to:
Module 13 Blue Cross and Blue Shield Plans1. Differentiate between primary and secondary commercial claims. 2. Complete commercial primary and secondary fee-for-service claims accurately. 3. Complete commercial primary supplemental fee-for-service claims accurately. 4. Create a comparison chart as an aid to mastering the detail of completing claims. Covered Topics Commercial Claims Step-by-Step Claim Instructions - Blocks Entering Patient and Policy Information Step-by-Step Claim Instructions - Blocks Dates of Service and Diagnosis Codes Step-by-Step Claim Instructions - Block Procedures, Services and Supplies Step-by-Step Claim Instructions - Blocks Provider Information Commercial Secondary Coverage Modifications to Primary CMS-1500 Claims Modifications to Secondary CMS-1500 Claims Objectives - Upon successful completion of this chapter, you should be able to:
Module 14 Medicare1. Define key terms. 2. Explain the function of the national Blue Cross and Blue Shield Association. 3. List four features that make BCBS plan different from other commercial plans. 4. List the advantages of being a BCBS participating provider. 5. Describe the features of a BCBS participating provider. 6. List typical services found in Major Medical coverage. 7. Explain the benefits of special accidental injury riders/clauses. 8. Explain the benefits of a medical emergency rider. 9. Describe the purpose of the BlueCard program. 10. Explain how a BlueCard patient is identified. 11. Compare how PARs and nonPARs process BlueCard claims. 12. Compare the major differences between BCBS, PPA and POS plans. 13. State the deadline for filing BCBS claims. 14. Complete BCBS claims accurately. Covered Topics History of Blue Cross and Blue Shield Blue Cross Blue Shield Plans Billing Information Summary Step-by-Step Claim Instructions BCBS Secondary Coverage Objectives - Upon successful completion of this chapter, you should be able to:
Module 15 Medicaid1. Define key terms. 2. List six categories of persons eligible for Medicare coverage. 3. Describe coverage for each of the following: Medicare Part A hospice care Medicare Part B heart transplant ESRD dialysis cases kidney donor 4. List and describe six incentives developed by Congress to encourage providers to become Medicare participating providers. 5. List and describe six restrictions placed on Medicare nonPAR providers. 6. Explain the requirements for use of the Medicare medical necessity statement. 7. Explain requirements governing use of the surgery financial disclosure statement. 8. List and define seven types of insurance programs that are primary to Medicare. 9. List and define two types of programs that are classified as Medicare supplemental plans. 10. Explain how a policy falls in to the extra coverage category and how it affects Medicare billing. 11. Explain how a Medicare claim is filed for Medicare patients enrolled in Medicare risk-restricted or cost-based HMO's. 12. Explain the billing sequence for Medicare patients with employer-sponsored plans, Medigap, Medicare-Medicaid crossover plans and Medicare as secondary coverage. 13. Explain how Medicare's liability as a secondary payer is calculated. 14. State the deadline for filing Medicare claims. 15. Discuss the provider's legal responsibility for collecting the patient's deductible and coinsurance obligations. 16. Explain the procedure health care providers must follow to "opt out" of Medicare. 17. Describe the features of Medicare+Choice with regard to the following: private fee-for-service plan, provider sponsored organizations and Medicare Savings Accounts. 18. File traditional Medicare or Medicare HMO fee-for-service claims properly. Covered Topics Medicare Eligibility Medicare Enrollment Medicare Part A Coverage Medicare Part B Coverage Participating Providers Nonparticipating Providers Private Contracting Advance Beneficiary Notice Medicare as a Secondary Payer Medicare Plans Billing Notes Step-by Step Claim Instructions Medicare with Medigap Claims Medicare-Medicaid Crossover Claims Medicare Secondary Payer (MSP) Claims Roster Billing for Mass Vaccination Programs Objectives - Upon successful completion of this chapter, you should be able to:
Module 16 Tricare1. Define key terms 2. List Medicaid federal guidelines. 3. List services covered under the federal portion of Medicaid assistance. 4. List services covered in your state that are not federally mandated services. 5. Explain how to verify a patient's Medicaid eligibility. 6. State the deadline for filing claims (timely filing period). 7. Explain the importance of the spousal impoverishment protection legislation. 8. Describe the preauthorization procedure for services. 9. File a Medicaid claim using the rules for the CMS-1500 claim. Covered Topics Federal Eligibility Requirements for Medicaid Medicaid Covered Services Medicare-Medicaid relationship Medicaid as a Secondary Payer Participating Providers Medicaid and Managed Care Medicaid Eligibility Verification System (MEVS) Medicaid Remittance Advice Utilization Review Fraud and Abuse Medical Necessity Billing Information Notes Step-by-Step Claim Instructions Medicaid as Secondary Claims Mother / Baby Claims Objectives - Upon successful completion of this chapter, you should be able to:
Module 17 Workers' Compensation1. Define key terms. 2. List TRICARE eligibility categories. 3. State TRICARE definitions for "medical emergency" and "urgent medical problem". 4. State TRICARE outpatient coverage for mental health and substance abuse. 5. Explain the meaning of TRICARE catastrophic coverage. 6. List six services not covered by TRICARE. 7. List type of health insurance to the TRICARE program. 8. List and define the three levels of TRICARE coverage. 9. State deductibles and cost-share for TRICARE Extra, Standard and Point-of-Service options. 10. File TRICARE Standard and Extra claims properly. Covered Topics Tricare Background Tricare Administration CHAMPVA Tricare Options Tricare Programs and Demonstration Projects Tricare Supplemental Plans Tricare Billing Information Tricare Primary Claim Instructions Primary Tricare with a Supplemental Policy Tricare as Secondary Payer Objectives - Upon successful completion of this chapter, you should be able to:
1. Define key terms. 2. List the categories of workers covered by the federal compensation program. 3. List and describe the types of workers' compensation available at the state level. 4. List and describe the classifications fo workers' compensation cases as stipulated by federal law. 5. Select proper terminology to describe "employee's diminished capacity." 6. Identify final destinations for the required copies of the First Report of Injury form. 7. Describe correct billing procedures for workers' compensation cases. 8. Explain the necessity for separating treatment data for work-related injuries and illnesses from those not related to the patient's employment. 9. List the forms necessary to properly file compensation claims. 10. File First Report of Injury reports and claims accurately. Covered Topics Federal Workers' Compensation Programs State Workers' Compensation Program Eligibility for Coverage Classification of Workers' Compensation Cases Special handling of Workers' Compensation Cases Workers' Compensation and Managed Care First Report of Injury Progress Reports Appeals and Adjudication Fraud and Abuse Billing Information Notes Workers' Compensation Claim Instructions - Patent and Policy Identification  | 
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