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Center for Curriculum and Transfer Articulation
Federal Employee Program Systems: Processing Claims
Course: CSR114

First Term: 2019 Fall
 Lecture   4.0 Credit(s)   4.0 Period(s)   4.0 Load  
Subject Type: Occupational
Load Formula: S- Standard


Description: Overview of the federal employee health benefit program and policies and procedures for processing claims. Covers benefit packages, covered services and costs, and coordination of benefits. Also included customer service standards and techniques.



MCCCD Official Course Competencies
1. Explain and use the Health Insurance Portability and Accountability Act. (I)
2. Describe how members obtain benefits. (I)
3. Explain the principles for First Call Resolution (FCR) and why they are important. (I)
4. Identify stages of calls and the call flow system. (I)
5. Summarize key elements for proper phone etiquette. (I)
6. Access various screens to research and respond to telephone inquiries. (I)
7. Research and process various claims. (I-V)
8. Summarize the Federal Employee Health Benefit (FEHB) Plan. (II)
9. Differentiate between various benefit options. (II)
10. Identify insurance groups in the FEHB Plan. (II)
11. Define Coordination of Benefits (COB). (II)
12. Differentiate between federal and government programs and carrier designation. (II)
13. Research different categories of claims. (III)
14. Explain steps for processing direct and deferred claims. (III)
15. Identify the necessary data corrections for deferred claims. (III)
16. Differentiate types of applications and their processing procedures. (IV)
17. Determine current status of claims. (IV)
18. Explain the process for adding and updating membership applications. (V)
19. Process membership applications. (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. Claims processing
   A. Overview
   B. Policies and procedures
      1. Health Insurance Portability and Accountability (HIPAA)
      2. Benefit policy
      3. Administration procedures
   C. Customer Service Solution (CSS)
      1. First Call Resolution (FCR)
      2. Standards
      3. Techniques
   D. Federal Employee Program (FEP)
   E. MetaVance
II. Eligibility benefits
   A. Federal Employee Health Benefit (FEHB) plan
      1. Overview
      2. Benefit options
      3. Insurance groups
   B. Coordination of Benefits (COB)
      1. Define
      2. Primary vs. secondary
      3. Deferrals
   C. Reimbursement
   D. Covered services
   E. Covered costs
      1. Plan allowance
      2. Out-of-pocket costs
III. Claim categories
   A. FEP direct claims deferrals
   B. Recoveries
   C. Correspondence
   D. Anesthesia
IV. Claim documents
   A. MetaVance claims
   B. Applications
   C. Medical records
   D. Correspondence
   E. Group
   F. Billing
V. Membership applications
   A. Process overview
      1. Types
      2. Procedures
      3. Steps
   B. Retrieve
   C. Resolve
   D. Resubmit
   E. Adjudication
   F. Adding/updating
 
MCCCD Governing Board Approval Date: May 17, 2016

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.