SRJC Course Outlines

7/15/2024 1:21:22 AMMA 168 Course Outline as of Fall 2019

Changed Course

Discipline and Nbr:  MA 168Title:  MEDICAL INSUR BILLING  
Full Title:  Basic Medical Office Insurance Billing
Last Reviewed:2/14/2022

UnitsCourse Hours per Week Nbr of WeeksCourse Hours Total
Maximum1.50Lecture Scheduled1.5017.5 max.Lecture Scheduled26.25
Minimum1.50Lab Scheduled06 min.Lab Scheduled0
 Contact DHR0 Contact DHR0
 Contact Total1.50 Contact Total26.25
 Non-contact DHR0 Non-contact DHR Total0

 Total Out of Class Hours:  52.50Total Student Learning Hours: 78.75 

Title 5 Category:  AA Degree Applicable
Grading:  Grade Only
Repeatability:  00 - Two Repeats if Grade was D, F, NC, or NP
Also Listed As: 
Formerly:  MA 68.1

Catalog Description:
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The student will develop basic knowledge and skills for understanding major health insurance plans as related to medical office billing.

Course Completion of HLC 160 and LIR 10

Recommended Preparation:
Eligibility for ENGL 1A or equivalent or appropriate placement based on AB705 mandates

Limits on Enrollment:

Schedule of Classes Information
Description: Untitled document
The student will develop basic knowledge and skills for understanding major health insurance plans as related to medical office billing.
(Grade Only)

Prerequisites:Course Completion of HLC 160 and LIR 10
Recommended:Eligibility for ENGL 1A or equivalent or appropriate placement based on AB705 mandates
Limits on Enrollment:
Transfer Credit:
Repeatability:00 - Two Repeats if Grade was D, F, NC, or NP


Associate Degree:Effective:Inactive:
CSU GE:Transfer Area Effective:Inactive:
IGETC:Transfer Area Effective:Inactive:
CSU Transfer:Effective:Inactive:
UC Transfer:Effective:Inactive:

Certificate/Major Applicable: Both Certificate and Major Applicable


Student Learning Outcomes:
At the conclusion of this course, the student should be able to:
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1.  Describe the major types of health insurance plans and use appropriate medical insurance
    billing and coding terminology.
2.  Analyze the claims process, pre-service authorization, patient and medical office
    responsibilities and guidelines for major insurance claims.
3.  Accurately complete a variety of health insurance claim forms extracting information from
    medical records and choosing appropriate diagnostic and procedural codes.

Objectives: Untitled document
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.   Extract from patient records information for completing insurance plans.
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 plans.
6.   Correctly choose appropriate coding books according to plan/billing regulations.
7.   Describe the differences between procedural and diagnostic coding books.
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  patient's
      chart notes.
10. Interpret benefits received and apply correctly to patient and office accounting records.
11. Fill out a prior authorization form.
12. Interpret Explanation of Benefits/Remittance Advice.
13  Identify fraud and abuse regulations.
14. Understand medical necessity as it relates to insurance claims.
15. Understanding changing healthcare regulations as they occur.

Topics and Scope
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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 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 implications
III. Major Types of Health Care Insurance Plans such as
     A. MediCal/Medicaid/CSMP/Partnership Health Plan
    B. Medicare/Medi-Medi
     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 for major plans ( i.e. Medicare and Military)
    D. Covered services
     E. Pre-authorization regulations and procedures
     F. Billing limitations and timelines
     G. Procedural and diagnostic coding requirements
V. Changes in Healthcare
    A. Affordable Care Act (ACA)
    B. Healthcare delivery changes
    C. Implementation and navigation of the ACA

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1. Read 30-50 pages of text per week
2  Review 10-20 questions for each assigned chapter
3. Complete 8-10 exercises related to developing beginning skills in correctly identifying
    procedural and diagnostic codes obtained from patient records
4. Prepare 4-6 typed insurance claims for representation of major insurance plans
5. Complete 1-2 written prior authorization forms
6. Identify diagnostic and procedural information from 2-4 patient charts for completion of
    insurance claims
7. Quizzes (3-6) and final exam
8. Paper 2-3 pages, on changes in healthcare

Methods of Evaluation/Basis of Grade.
Writing: Assessment tools that demonstrate writing skill and/or require students to select, organize and explain ideas in writing.Writing
20 - 35%
Coding exercises, typed insurance claims, changes in healthcare paper, written prior authorization forms
Problem solving: Assessment tools, other than exams, that demonstrate competence in computational or non-computational problem solving skills.Problem Solving
10 - 30%
Homework problems: chapter questions, identification of procedural and diagnostic codes
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
40 - 70%
Quizzes and final exam
Other: Includes any assessment tools that do not logically fit into the above categories.Other Category
0 - 0%

Representative Textbooks and Materials:
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Understanding Health Insurance: A Guide to Billing and Reimbursement. 14th ed. Green, Michelle. 2019

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