|9/23/2023 6:39:02 AM||
|Discipline and Nbr:
MEDICAL INSUR BILLING||
Basic Medical Office Insurance Billing
|Units||Course Hours per Week|| ||Nbr of Weeks||Course Hours Total
|Maximum||1.50||Lecture Scheduled||2.00||8 max.||Lecture Scheduled||16.00
|Minimum||1.50||Lab Scheduled||3.00||8 min.||Lab Scheduled||24.00
| ||Contact DHR||0|| ||Contact DHR||0
| ||Contact Total||5.00|| ||Contact Total||40.00
| ||Non-contact DHR||0|| ||Non-contact DHR Total||0
Title 5 Category:
AA Degree Applicable
00 - Two Repeats if Grade was D, F, NC, or NP
Also Listed As:
| ||Total Out of Class Hours: 32.00||Total Student Learning Hours: 72.00||
The student will develop basic knowledge and skills for accurately processing major health plans'insurance claims for a medical office.
Eligibility for ENGL 100 or ESL 100
Limits on Enrollment:
Schedule of Classes Information
The student will develop basic knowledge and skills for accurate processing of major health plans' insurance claims for a medical office.
Recommended:Eligibility for ENGL 100 or ESL 100
Limits on Enrollment:
Repeatability:00 - Two Repeats if Grade was D, F, NC, or NP
ARTICULATION, MAJOR, and CERTIFICATION INFORMATION
Both Certificate and Major Applicable
Outcomes and Objectives:
At the conclusion of this course, the student should be able to:
|CSU GE:||Transfer Area|| ||Effective:||Inactive:
|IGETC:||Transfer Area|| ||Effective:||Inactive:
Upon completion of this course, the students will be able to:
1. Define common insurance medical and diagnostic terms.
2. Describe the major federal, state, and private health insurance plans.
3. Abstract from patient records information for completing insurance
4. List criteria for eligibility, benefits, payments, time lines, billing
limitations, deductibles, and forms for major plans.
5. Explain the procedures and criteria for prior authorizations for major
6. Correctly choose appropriate coding books according to plan
7. Describe the differences between procedural and diagnostic coding
8. Code basic levels of service and procedures properly, using the
appropriate coding books and specific guidelines for each plan.
9. Accurately complete a series of health insurance claims for various
plans, given the patient's chart notes and ledger cards.
10. Use the computer to develop skills in completing health claims forms
and choosing procedural and diagnostic codes.
11. Interpret benefits received and apply correctly to patient and office
12. Locate errors on medical insurance claim forms.
13. Complete insurance claim tracer forms.
14. List specific coding tips for specific plans.
15. Develop procedures for handling denials, rejections, delinquent
filings, and appeals.
Topics and Scope
I. Introduction to Medical Insurance
A. Types of medical insurance
B. Terminology of medical insurance
C. Introduction to procedural and diagnostic coding
II. The Health Insurance Claim Form
A. Claims process
B. Pre-service estimates and authorizations
C. Patient responsibilities
D. Medical office responsibilities
E. Preparation of the form: procedures, instructions
F. Requirements of the three major fiscal agents
G. Special problems: abstracting information, timelines, legal
III. Major Types of Health Care Insurance Plans such as
A. MediCal/Medicaid/CSMP (Children's Medical Security Plan) /CCS
(California Children's Services)
C. Blue Cross/ Blue Shield
D. HMO'S, PPO'S, IPO'S (Health Maintenance Organizations, Preferred
Provider Organizations, Independent Provider Organizations)
E. Disability: Workers Compensation
IV. Criteria and Guidelines for Major Plans
A. Benefits and eligibility
B. Participating providers' responsibilities
C. Schedules of deductibles and fee payments
D. Covered services
E. Pre-authorization regulations and procedures
F. Billing limitations and timelines
G. Recent and specific coding requirements
H. Other regulations and hints
1. Read 30-50 pages of text per week.
2. Complete writing assignments including:
A. Review questions for assigned chapters.
B. Exercises related to developing beginning skills in correctly
identifying procedural and diagnostic codes obtained from
C. Preparation of typed insurance claims for major plans.
3. Complete written prior authorization claims.
4. Problem Solving:
A. Complete a chart listing criteria for major health plans.
B. Abstract information from patient charts for correct completion
of insurance claims.
C. Complete a series of computer-based programs to prepare a
variety of health insurance claims forms.
5. Quizzes (3-6) and final exam.
Methods of Evaluation/Basis of Grade.
Representative Textbooks and Materials:
|Writing: Assessment tools that demonstrate writing skill and/or require students to select, organize and explain ideas in writing.||Writing
20 - 35%
|Problem solving: Assessment tools, other than exams, that demonstrate competence in computational or non-computational problem solving skills.||Problem Solving
40 - 70%
|Homework problems, Lab reports||
|Skill Demonstrations: All skill-based and physical demonstrations used for assessment purposes including skill performance exams.||Skill Demonstrations
0 - 0%
|Exams: All forms of formal testing, other than skill performance exams.||Exams
10 - 30%
|Multiple choice, Matching items, Completion||
|Other: Includes any assessment tools that do not logically fit into the above categories.||Other Category
0 - 0%
INSURANCE HANDBOOK FOR THE MEDICAL OFFICE by Marilyn Fordney, W.B.
Saunders Co., 2003.