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Center for Curriculum and Transfer Articulation
Health Claims Processing I
Course: CSR216

First Term: 2009 Summer I
 Lecture   2 Credit(s)   2 Period(s)   2 Load  
Subject Type: Occupational
Load Formula: S


Description: Overview of healthcare claims processing applications. Emphasis on use of a healthcare claims processing system. Includes quality review procedures and responsibilities.



MCCCD Official Course Competencies
1. Explain the use of a healthcare claims processing system in the claims flow process. (I)
2. Explain the use of online resources. (I)
3. Identify elements of various medical forms. (I)
4. Describe the adjudication process in claims processing. (II)
5. Differentiate between claim status and edit status. (II)
6. Review procedures for completing pends and edits. (II)
7. Summarize quality review responsibilities. (III)
8. Review accuracy standards. (III)
9. Explain procedures for filing a rebuttal. (III)
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. Features
   B. Terminology
   C. System
      1. Environments
      2. Structures
      3. Modules
      4. Access
      5. Claims Processing
      6. Research
      7. Data Entry
   D. Workflow
      1. Life of a Claim
      2. Role
      3. Changes
   E. Online Resources
      1. Procedures
      2. Tool Kits
      3. Claims Training Updates (CTU)
      4. Access
   F. Medical Forms
      1. Types
      2. Service Codes
      3. Diagnostic Codes
      4. Revenue Codes
      5. Terminology
II. Edits, Pend Codes, Pend Reports
   A. Edit Function
      1. Adjudication
      2. Edits Tab
      3. Claim Tab Claim Status
      4. Procedures
   B. Pend Code Assignment
      1. List
      2. Reports
      3. Resolution
      4. Memos
      5. Screens
III. Quality Review
   A. Team
      1. Supervisor
      2. Quality Reviewer
      3. Quality Monitor
   B. Responsibilities
      1. Trend Identification
      2. Policy Compliance
      3. Corrective Action
   C. Audits
      1. Random
      2. Overvalue
   D. Errors
      1. Procedural
      2. Payment
   E. Rebuttals
 
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.