MEAS 137 - Outpatient Insurance and Basic Coding

1. Identify: (VIII.C.1)
   1. Types of third party plans
   2. Information required to file a third party claim
   3. The steps for filing a third party claim
2. Outline managed care requirements for patient referral (VIII.C.2)
3. Describe processes for: (VIII.C.3)
   1. Verification of eligibility of services
   2. Precertification
   3. Preauthorization
4. Differentiate between fraud and abuse (VIII.C.5)
5. Interpret information on an insurance card (VIII.P.1)
6. Verify eligibility for services including documentation (VIII.P.2)
7. Obtain precertification or preauthorization including documentation (VIII.P.3)
8. Complete an insurance form (VIII.P.4)
9. Interact professionally with third party representatives (VIII.A.1)
10. Display tactful behavior when communicating with medical providers, regarding third party requirements (VIII.A.2)
11. Show sensitivity when communicating with patients regarding third party requirements (VIII.A.3)
12. Describe how to use the most current procedural coding system (IX.C.1)
13. Describe how to use the most current diagnostic coding classification system (IX.C.2)
14. Describe how to use the most current HCPCS Level II coding system (IX.C.3)
15. Discuss the effects of:
    1. Upcoding
    2. Downcoding (IX.C.4)
16. Define medical necessity as it applies to procedural and diagnostic coding (IX.C.5)
17. Perform procedural coding (IX.P.1)
18. Perform diagnostic coding (IX.P.2)
19. Utilize medical necessity guidelines (IX.P.3)
20. Utilize tactful communication skills with medical providers to ensure accurate code selection (IX.A.1)
21. Define a patient-centered medical home (PCMH) (VIII.C.4)

Health insurance plans

Processing insurance claim forms

Third party reimbursement

Procedural coding

Diagnostic coding
Course Addendum - Syllabus (Click to expand)