MEAS 204 - Advanced Insurance Claims Processing

1. List and discuss the responsibilities and skills required for the Health Insurance Specialist.
2. Describe the Health Insurance Portability and Accountability Act of 1996 and how it defines insurance fraud and abuse.
3. Explain the reimbursement methods used by different insurance companies.
4. Code accurately using the ICD-10, CPT, and HCPS coding systems at an advanced level.
5. Complete claim forms accurately using both paper copy and computer.
6. Describe electronic claims processing.
7. Analyze and compare EOB’s from the major insurance carriers.
8. Explain claims tracking and follow-up as they relate to aged accounts.
9. Explain the use of insurance bulletins, journals, and seminar data.
10. Describe the process and importance of obtaining prior authorization (referrals) on behalf of patients.
11. Explain the process of updating patient information and changing a patient’s insurance electronically.
12. List the steps needed when a patient has multiple insurance companies.
13. Describe Medicare and Medicaid processing, appeals, refunds and verification.
14. Write appeals letters to insurance companies with justification of coding applications.
15. Explain what is needed for a contractual write-off.
16. Describe remittance codes.

Job duties of the Health Insurance Specialist

Vocabulary used in healthcare insurance and medical billing

HIPAA and its application to health insurance and medical billing

Collection of patient information

Updating patient information

Medicare guidelines for insurance processing

Medicaid guidelines for insurance processing

Currently used coding systems including CPT, ICD-10, and HCPS

Major insurance companies and their policies and procedures

Analyzing the insurance members’ ID

Accurate submission of claims

Analyzing the EOB and remittance code

Pre-authorization and referral

Appeal letters

Refunds to patient and insurance companies

Write-offs items
Course Addendum - Syllabus (Click to expand)