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Center for Curriculum and Transfer Articulation
Health Claims Processing III
Course: CSR218

First Term: 2018 Fall
 Lec + Lab   3.0 Credit(s)   4.0 Period(s)   4.0 Load  
Subject Type: Occupational
Load Formula: T


Description: Procedures for completing benefits and contracts requirements. Includes prior authorization guidelines and procedures as well as claim splitting. iHealth components and claim adjustments and reversals also covered.



MCCCD Official Course Competencies
1. Complete contract edits. (I)
2. Explain member responsibility with regard to edits. (I)
3. Explain the relationship between provider, claim and contract components. (I)
4. Demonstrate procedures for manually pricing a claim. (I)
5. Explain the relationship between member, claim, and benefit components. (I)
6. Summarize prior authorization issues. (II)
7. Demonstrate procedures for resolution of prior authorization issues. (II)
8. Identify and explain eligibility components. (III)
9. Determine number of days in an enrollment segment. (III)
10. Demonstrate procedures for splitting a claim. (III)
11. Identify components of an iHealth claim. (IV)
12. Explain claim status. (V)
13. Practice retrieving claim form images. (V)
14. Demonstrate procedures for an adjustment and retrieval. (V)
15. Complete payment and denial research. (V)
16. Create a call record. (VI)
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. Benefits and Contracts
   A. Edits
      1. Definition
      2. Components
      3. Use
      4. Procedures
      5. Content
      6. Member Responsibility
   B. Contract Review
      1. Claim
      2. Provider
      3. Contract
      4. Navigation
      5. Terminology
   C. Contract Manual Review
      1. Definition
      2. Guidelines
      3. Procedures
      4. Long Description
      5. Terminology
   D. Benefit Review
      1. Member
      2. Claim
      3. Benefit
      4. Terminology
   E. Benefit Term Manual Review
      1. Use
      2. Procedures
      3. Guidelines
      4. Long Description
      5. Claim Service History
   F. Benefit Requires Documentation
II. Prior Authorization
   A. Flow
   B. Guidelines
      1. Facility Authorization
      2. Provider Authorization
   C. Emergency, Radiology, Anesthesiology and Pathology (ERAP)
      1. Procedures
      2. Determination
   D. Authorization Status
   E. Authorization Management Module
      1. Use
      2. Navigation
   F. Inpatient Hospital
      1. Claim Identification
      2. Terminology
      3. Revenue Codes
   G. Claim Vs Authorization
      1. Procedures
      2. Down Coding
   H. Invalid Accommodation Days
III. Claim Splitting
   A. Terminology
   B. Dates of Service
   C. Eligibility Components
      1. Plan
      2. Effective Date
      3. Termination Date
      4. Rate Code
   D. Guidelines
   E. Day Calculation
      1. Fields
      2. Dates
   F. Calculator
   G. Physicians/Healthcare Professionals
   H. Facilities
IV. iHealth
   A. Components
      1. Claim Status
      2. Memos
      3. Edits
   B. Process Flow
   C. Guidelines
V. Claim Adjustments and Reversals
   A. Claim Status
      1. Definition
      2. Impact
   B. Terminology
   C. Identification Components
      1. Claim History
      2. Status
      3. Memos
   D. Payment and Denial Research
      1. Definition
      2. Components
      3. Procedures
      4. Claim Pull
   E. Adjusting the Claim
      1. Guidelines
      2. Procedures
VI. Call Tracking
   A. Call Record Creation
      1. Components
      2. Procedures
      3. Call Manage Tab
   B. Call Assignment
      1. Procedures
      2. Issue Manage Tab
   C. Call Resolution
      1. Procedures
      2. Issue Resolution Tab
 
MCCCD Governing Board Approval Date: 5/26/2009

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.