MCCCD Program Description

Health Care Insurance: Claims III

Course: CSR138

First Term: 2018 Summer

Lec + Lab 4.0 Credit(s) 6.0 Period(s) 5.4 Load
Subject Type: Occupational
Load Formula: S - Standard Load

Description: Overview of computer usage in the health care insurance industry. Covers various on-line systems/applications, benefit plans and screens, eligibility, pre-certification, and claims pricing. Claims processing emphasized.

MCCCD Official Course Competencies
1. Review the types of benefit plans. (I) 2. Differentiate between a Preferred Provider Organization (PPO), an Exclusive Provider Organization (EPO), and a Health Maintenance Organization (HMO). (I) 3. Access various benefit screens. (II) 4. Identify fields containing key benefit information. (II) 5. Explain the establishment of the Affordable Care Act (ACA). (III) 6. Explain important provisions of the Affordable Care Act (ACA) and how they affect the insurance industry. (III) 7. Summarize the policies and procedures for the Health Insurance Portability and Accountability Act (HIPAA). (III) 8. Determine member and provider eligibility. (IV) 9. Recognize individual versus employer group contracts. (IV) 10. Evaluate types of contracts for the service provider. (IV) 11. Discuss elements of provider`s contract. (IV) 12. Determine if a claim was entered and processed correctly. (V) 13. Explain the steps of adjudication and the collection points used for claims processing. (V) 14. Summarize data correction procedures required to process a claim. (V) 15. Practice data corrections. (V)
MCCCD Official Course Competencies must be coordinated with the content outline so that each major point in the outline serves one or more competencies. MCCCD faculty retains authority in determining the pedagogical approach, methodology, content sequencing, and assessment metrics for student work. Please see individual course syllabi for additional information, including specific course requirements.

MCCCD Official Course Outline
I. Benefit plans A. Types B. Preferred Provider Organization (PPO) C. Exclusive Provider Organization (EPO) D. Health Maintenance Organization (HMO) II. Benefit screens A. Terms B. Access C. Field descriptions III. Regulations A. Affordable Care Act (ACA) 1. Health reform 2. Health insurance marketplace 3. Health plans B. Health Insurance Portability and Accountability Act (HIPAA) IV. Eligibility A. Subscriber/member B. Employer groups 1. Small group 2. Large group C. Service provider 1. Contracted 2. Non-contracted 3. Multiple provider contracts V. Claims processing A. Key fields and descriptions B. Claim remarks C. Steps of adjudication validation D. Data corrections procedures E. Process pending claims

MCCCD Governing Board Approval Date: May 1, 2018

All information published is subject to change without notice. Every effort has been made to ensure the accuracy of information presented, but based on the dynamic nature of the curricular process, course and program information is subject to change in order to reflect the most current information available.