Guide to Health Claims Examining

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Product Details

  • ISBN-13: 9780131718531
  • Publisher: Prentice Hall
  • Publication date: 4/15/2005
  • Product dimensions: 8.26 (w) x 10.84 (h) x 1.06 (d)

Table of Contents

(Note: Each chapter contains Summary, Assignments, Questions for Review, and Honors for Certification.)

1.Introduction to Insurance.

The Rising Cost of Health Care.

Employee Benefits.

Types of Insurance.

Type of Health Benefit Plans.

Departments in an Insurance Company.

Claims Examiner's Responsibilities.

The Department of Insurance.

2. Legal Issues.

Disclaimers.

Privacy Guidelines.

Fraud.

HIPAA and Fraud and Abuse.

Investigation.

Checkpoints for Spotting Provider Fraud and Insurance Abuse.

Embezzlement.

Legal Damages.

Maintenance of Records.

Subpoenas.

Exercises.

3. Billing Forms.

CMS-1500 Form.

UB-92.

Exercises.

Appendix 3-1 Hospital Revenue Codes.

4. Resource Manuals.

ICD-9.

CPT/RVS.

HCPCS.

Physicians Desk Reference (PDR).

Medical Dictionary.

Merck Manual.

Red Book and Blue Book.

Exercises.

5. Contracts.

Contract Validity.

Group Contracts.

Contract Provisions.

Contract Benefits.

Exclusions.

Exercises.

6. Eligibility.

Employee Eligibility.

Dependent Eligibility.

Employee Effective Date of Coverage.

Dependent Effective Date of Coverage.

Open Enrollment.

Termination of Coverage.

Continuation of Coverage.

HIPAA.

Exercises.

7. Usual, Customary, and Reasonable.

Resource-Based Relative Value Study.

Calculating UCR.

Fee Schedules.

Exercises.

8. Benefit Structures.

Benefit Definitions.

Benefit Calculations.

Calculating Deductible.

BasicBenefits.

Common Basic Benefits.

Basic Major Medical Benefits.

Comprehensive Major Medical Benefits.

Computing Stoploss.

Exercises.

9. Cost-Containment Programs.

Preadmission Testing.

Pre-certification of Inpatient Admissions.

Utilization Review.

Second Surgical Opinion Consultations.

Managed Care.

Medical Case Management.

Appendix 9-1 Potential Medical Case.

Management Claims.

10. General Plan Provisions.

Acts of Third Parties.

Completion of the Right of Reimbursement.

Claims Ledger Sheet.

Subrogation.

Pre-existing Conditions.

Mandates.

Mental Health Parity Act.

Exercises.

Appendix 10-1 Possible Pre-existing Conditions.

11. Claims Administration.

Maintenance of Claim Files.

Claim File Documentation.

Claim Investigation.

Referrals.

Pended Claims.

Claim Processing.

Good Claim Practices.

Payment Worksheet.

Processing the Claim.

Quick Reference Formulas.

Prescription Drug Claims.

12. Effective Communication.

Verbal Communication.

Letter Writing.

Letter Structure.

Terminology.

Content.

Proofreading.

Claimant.

Physician.

Other Contacts.

Communication of Details.

Conclusions and Alternatives.

Notice of Availability.

Right of Review/ERISA.

Adjustments.

Exercise.

13. Physician's Services.

CPT Coding.

Maintenance Therapy.

Modifiers.

Exercises.

14. X-ray and Laboratory.

Services.

Radiology (X-ray).

Pathology (Lab).

General Guidelines.

Component Charges.

Exercises.

15. Surgery.

Surgical Procedures.

Surgery and the CPT.

General Guidelines.

Maternity Expenses.

Cosmetic Surgery.

Obesity Surgery.

Co-Surgeons.

Assistant Surgeons.

Exercises.

Appendix 15-1 Assistant Surgeon.

Procedures.

16. Podiatric Surgery.

General Guidelines.

Surgical Coding.

Conditions of the Foot and Treatment.

Procedures.

Assistant Surgeon.

Referrals.

17. Anesthesia.

General Anesthesia.

Regional Anesthesia.

Intravenous Sedation.

Acupuncture.

Hypnosis.

Anesthesia CPT Coding.

Handling Procedures.

Calculating Anesthesia.

Modifiers.

Unusual Circumstances.

Qualifying Circumstances.

Monitored Anesthesia Care.

Medical Direction of Anesthesiology.

Pain Control.

Miscellaneous.

Exercises.

18.Hospital Services.

UB-92 Billing Form.

Inpatient Hospital Claims.

Outpatient Hospital Claims.

Miscellaneous Facilities.

Exercises.

19. Ambulance Expenses.

Guidelines for Coverage.

Air Ambulance.

Paramedics.

Mobile Intensive Care Unit.

Van Transportation Unit.

Exercises.

20. Durable Medical Equipment.

DME Billing Procedures.

Prosthetic Devices.

Medical/Surgical Supplies.

Exercises.

Appendix 20-1 Durable Medical Equipment Coverage Guidelines.

21. Managed Care.

HMO Coverage.

Groups/IPAs.

Capitation Payments.

Authorizations, Referrals and Second Opinions.

Miscellaneous Services.

Claim Payments.

Processing the Claim.

Denial of a Claim or Services.

Appeals.

Reinsurance/Stoploss.

Exercises.

Appendix 21-1.

Appendix 21-2.

Appendix 21-3.

22. Coordination of Benefits.

Definitions.

Order of Benefit Determination Rules.

Right to Receive and Release Information.

Facility of Payment.

Right of Recovery.

Miscellaneous Guidelines.

Health Maintenance Organizations.

Preferred Provider Organizations.

TRICARE.

Recognizing the Presence of Dual Coverage.

COB Worksheet.

Exercises.

23. Medicare.

TEFRA/DEFRA.

Medicare Eligibility.

Providers of Service.

The Two Parts of Medicare.

Approved or Reasonable Charges.

Medicare Assignment of Benefits.

COB with Medicare.

Estimating Medicare Coverage.

Diagnosis-Related Group Billing.

Exercise.

24. Medicaid.

Health Insurance Payment Demand.

Handling Procedures.

25. Workers' Compensation.

Employee Activities.

Types of Claims.

Patient Records.

Doctor's First Report.

Subsequent Progress Reports.

Physician's Final Report.

Delay of Adjudication.

Fraud and Abuse.

Liens.

Reversals.

26. Adjustments.

Statistical Adjustment.

Supplemental Adjustment.

Full-Credit Adjustment.

Partial Credit Adjustment.

27. Dental Terminology.

Common Dental Terms and Procedures.

Exercises.

28. Anatomy and Physiology of the Mouth.

The Oral Cavity.

The Jaw.

Diseases of the Mouth.

The Teeth.

Growth and Development of Teeth.

Diseases of the Teeth.

Exercises.

29. Dental Services and Coding.

Dental Professionals.

Dental Treatment.

Dental Coding.

Diagnostic.

Preventive.

Restorative.

Endodontics.

Periodontics

Prosthodontics.

Oral Surgery.

Orthodontic Services.

Adjunctive General Services.

30. Temporomandibular Joint.

Dysfunction.

Coverage for TMJ.

Appliances.

Services and Supplies.

31. Dental Claim Form.

The ADA Dental Claim Form.

Patient Information Sheet.

32. Dental Benefit Structures.

Types of Dental Plans.

Understanding Dental Contracts.

General Guidelines.

Cost Containment.

Major Medical Coverage for Dental.

Procedures.

Temporary Restorations.

X-Rays.

Anesthesia.

Sedative Fillings.

Cosmetic Services.

Unspecified and By Report Procedures.

33. Processing Dental Claims.

The Claim Form.

Eligibility.

Other Insurance.

Provider Authority.

Coverage of Services.

Evaluating the Services.

Processing the Claim.

Completing the Claim Payment Worksheet.

Dental Form Letters.

Handling Fraudulent Dental Claims.

Exercises.

Appendix 33-1 Dental Prevailing.

Conversion Factors.

Appendix 33-2 Dental RVS Unit Values.

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