12/27/2024 6:42:53 AM	MA 168 Course Outline as of Fall 2020	Changed Course
CATALOG INFORMATION
Discipline and Nbr:  MA 168	Title:  MEDICAL INSUR BILLING
Full Title:  Basic Medical Office Insurance Billing
Last Reviewed:2/14/2022

Units		Course Hours per Week			Nbr of Weeks	Course Hours Total
Maximum	1.50	Lecture Scheduled	1.50		17.5 max.	Lecture Scheduled	26.25
Minimum	1.50	Lab Scheduled	0		17.5 min.	Lab Scheduled	0
		Contact DHR	0			Contact DHR	0
		Contact Total	1.50			Contact Total	26.25
		Non-contact DHR	0			Non-contact DHR Total	0

Total Out of Class Hours:  52.50

Total 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:

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

Prerequisites/Corequisites:
Course Completion of MA 160, MA 161, MA 162, MA 163, MA 167; AND Concurrent Enrollment in MA 164, MA 165, MA 169, and MA 174

Recommended Preparation:
Eligibility for ENGL 1A or equivalent

Limits on Enrollment:

Schedule of Classes Information
Description:

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 MA 160, MA 161, MA 162, MA 163, MA 167; AND Concurrent Enrollment in MA 164, MA 165, MA 169, and MA 174
Recommended:Eligibility for ENGL 1A or equivalent
Limits on Enrollment:
Transfer Credit:
Repeatability:00 - Two Repeats if Grade was D, F, NC, or NP

ARTICULATION, MAJOR, and CERTIFICATION INFORMATION

Associate Degree:		Effective:		Inactive:
Area:
CSU GE:	Transfer Area			Effective:	Inactive:
IGETC:	Transfer Area			Effective:	Inactive:
CSU Transfer:		Effective:		Inactive:
UC Transfer:		Effective:		Inactive:
C-ID:

Certificate/Major Applicable: Both Certificate and Major Applicable

COURSE CONTENT

Student Learning Outcomes:
At the conclusion of this course, the student should be able to:

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:

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

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

Assignments:

1. Read 30-50 pages of text per week

2. Complete 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%
None
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%
None

Representative Textbooks and Materials:

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

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