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Center for Curriculum and Transfer Articulation
Health Care Insurance: Claims II
Course: CSR137

First Term: 2018 Summer
 Lec + Lab   2.0 Credit(s)   3.0 Period(s)   2.7 Load  
Subject Type: Occupational
Load Formula: S- Standard


Description: Guidelines and procedures for finalizing claims. Covers research and manual pricing procedures, adjudication, and claim liability in addition to procedures for completing cutbacks and recovery.



MCCCD Official Course Competencies
1. Access and interpret Medical Coverage Guidelines and Pricing Guidelines. (I)
2. Research and interpret claim status. (I)
3. Manually price claims. (I)
4. Apply claim liability. (I)
5. Use coding audit software. (I, II)
6. Evaluate claims. (I, II)
7. Process cutbacks. (II)
8. Complete recovery procedures. (II)
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. Adjudication pricing
   A. Guidelines
      1. Medical coverage
      2. Pricing
   B. Claims
      1. Types
      2. Access
      3. Liability
   C. Research
      1. Types
      2. Procedures
      3. Source documents
   D. Benefit narrative
   E. Diagnostic Related Grouping (DRG)
   F. Pricing management
   G. Fee schedules
   H. Forms
II. Audit
   A. Coding
      1. Schemes
      2. Guidelines
      3. Procedures
   B. Validation
   C. Adjudication
   D. Cutbacks
      1. Single line
      2. Multi-line
      3. Sprinkle
      4. To deny
   E. Adjustments
      1. Types
      2. Procedures
   F. Documentation
   G. Recovery
      1. Types
      2. Procedures
 
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.