Course

10160177 Specialized Insurance Claims
Course Information
Description
Identifies in-depth insurance knowledge following the healthcare revenue cycle. Explore healthcare law. Investigate private payers, Medicare, Medicaid, TRICARE, CHAMPVA, worker's compensation, and disability insurance. Knowledge of deductibles, coinsurance, copayments, exclusions, medical necessity, referrals, prior authorization, coordination of benefits, COBRA, Charity Care, collections, pre-existing periods, allowed amounts, malpractice, outpatient benefits, and lifetime maximums. Intermediate diagnostic, procedural, and HCPCS coding. Claims reimbursement methods, contractual allowances, fee schedules, and other rules to facilitate timely payment of claims.
Total Credits
2
Course Competencies (Course Outcomes)
  1. Explore the medical billing specialist field.
    Assessment Strategies
    Written product or oral analysis
    Quiz
    Criteria
    you participate in discussions analyzing the medical billing specialist field.
    reflection includes a description of duties in the profession
    reflection summarizes common billing processes in healthcare
    you achieve a minimum of 76% on the quiz.

  2. Be sensitive to the importance of keeping medical records private and secure.
    Assessment Strategies
    Research project
    Quiz
    Criteria
    project includes evidence of external research related to HIPAA, HITECH, and other privacy laws.
    project includes four elements of privacy and security laws
    project lists the responsibilities of the medical billing specialist related to patient privacy and security laws
    you achieve 76% on the quiz.

  3. Illustrate knowledge of diagnostic coding.
    Assessment Strategies
    Skill Demonstration
    Quiz
    Criteria
    you identify the primary diagnosis and coexisting conditions.
    you utilize ICD-10-CM format to assign accurate codes.
    you assign accurate diagnoses and external cause codes.
    you achieve a minimum of 76% on the quiz.

  4. Illustrate knowledge of procedural coding.
    Assessment Strategies
    Skill Demonstration
    Quiz
    Criteria
    you accurately identify procedures to be coded.
    you accurately identify Evaluation and Management (EM) codes.
    you utilize correct CPT format to assign accurate procedure codes.
    you assign accurate HCPCS procedure codes.
    you achieve a minimum of 76% on the quiz.

  5. Investigate healthcare payment methods.
    Assessment Strategies
    Project
    Critique
    Quiz
    Criteria
    presentation meets minimum requirements of grading rubric
    you create a presentation for the class on an assigned topic.
    you view presentations on payment arrangements, processes, and rules
    you reflect on presentations and provide critiques.
    you achieve a minimum of 76% on the quiz.

  6. Conduct healthcare claim preparation.
    Assessment Strategies
    Written product - form
    Quiz
    Criteria
    you accurately abstract insurance information
    CMS-1500 claim form is completed accurately so payment is processed and not denied
    you achieve a minimum of 76% on the quiz.

  7. Examine private payers/BlueCross BlueShield.
    Assessment Strategies
    Skill Demonstration
    Quiz
    Criteria
    CMS-1500 claim form for private payers is 100% accurate
    you accurately calculate patient and payer balances for participating and nonparticipating private payers.
    you achieve a minimum of 76% on the quiz.

  8. Explore Medicare.
    Assessment Strategies
    Research project
    Quiz
    Criteria
    you achieve a minimum of 76% on a Medicare website scavenger hunt.
    you achieve a minimum of 76% on the quiz.

  9. Explore Medicaid.
    Assessment Strategies
    Research Project - Blog response
    Quiz
    Criteria
    research project compares Wisconsin's Medicaid program to another state.
    blog response utilizes accurate grammar and punctuation.
    you achieve a minimum of 76% on the quiz.

  10. Explore TRICARE and CHAMPVA.
    Assessment Strategies
    Research project
    Skill Demonstration
    Quiz
    Criteria
    you explore the TRICARE and CHAMPVA websites.
    you participate in course wiki.
    you accurately complete CMS-1500 claims for for TRICARE/CHAMPVA patients.
    you achieve a minimum of 76% on the quiz.

  11. Examine the Worker's Compensation system.
    Assessment Strategies
    Skill Demonstration
    Quiz
    Criteria
    you accurately complete CMS-1500 claim form for a Worker's Compensation claim.
    you achieve a minimum of 76% on the quiz.

  12. Investigate Disability compensation.
    Assessment Strategies
    Quiz
    Criteria
    you achieve a minimum of 76% on the quiz.

  13. Identify inpatient and outpatient hospital billing processes.
    Assessment Strategies
    Written Product
    Quiz
    Criteria
    you accurately compare and contrast inpatient and outpatient hospital services.
    you accurately discuss hospital coding processes.
    you achieve a minimum of 76% on the quiz.

  14. Investigate payments, appeals, and secondary claims
    Assessment Strategies
    Presentation
    Critique
    Quiz
    Written product - collection letter
    Criteria
    you create a presentation for the class on an assigned topic.
    you view presentations on payments, appeals, and secondary claims.
    you reflect on presentations and provide critiques.
    you achieve a minimum of 76% on the quiz.
    you accurately calculate patient and payer balances.
    collection letter utilizes correct business and grammar guidelines and is 100% accurate