MEAS 137 - Outpatient Insurance and Basic Coding

1. Identify: (VIII.C.1)
   1. types of third party plans
   2.  steps for filing a third party claim
2. Identify managed care requirements for patient referral (VIII.C.2)
3. Identify processes for: (VIII.C.3)
   1. Verification for eligibility of services
   2. Precertification/Preauthorization
   3. Tracking unpaid claims
   4. Claim denials and appeals
4. Identify fraud and abuse as they related to third-party reimbursement. (VIII.C.4)
5. Define the following: (VIII.C.5)
   1. Bundling and unbundling of codes
   2. Advanced beneficiary notice (ABN)
   3. Allowed amount
   4. Deductible
   5. Co-insurance
   6. Co-pay
6. Identify the purpose and components of the Explanation of Benefits (EOB) and Remittance Advice (RA) Statements (VIII.C.6)
7. Interpret information on an insurance card (VIII.P.1)
8. Verify eligibility for services (VIII.P.2)
9. Obtain precertification or preauthorization with documentation (VIII.P.3)
10. Complete an insurance claim form (VIII.P.4)
11. Assist a patient in understanding an Explanation of Benefits (EOB) (VIII.P.5)
12. Identify the current procedural and diagnostic coding systems, including Healthcare-Common Procedure Coding Systems II (HCPCS Level II) (IX.C.1)
13. Identify the effects of: (IX.C.2)
    1. Upcoding
    2. Downcoding 
14. Define medical necessity (IX.C.3)
15. Perform procedural coding (IX.P.1)
16. Perform diagnostic coding (IX.P.2)
17. Utilize medical necessity guidelines (IX.P.3)

• Health insurance plans
• Processing insurance claim forms
• Third party reimbursement
• Procedural coding
• Diagnostic coding

 
Course Addendum - Syllabus (Click to expand)