Rent 9780766813083 | Understanding Health Insurance : A Guide to Professional Billing

Summary Table of Contents

nderstanding Health Insurance is a comprehensive guide for those learning about health insurance claim processing. Objectives of this edition are 1) to introduce information about major insurance programs and federal health care legislation, 2) to provide basic information on national diagnosis and procedure coding systems and 3) simplify the process of completing claim forms. Contains pertinent, easy-to-understand information on common health insurance plans, with separate chapters on coding and reimbursement issues, and step-by-step instructions for HCFA-1500 claim completion. Case studies and review exercises give users numerous opportunities to apply knowledge to build skill in completing HCFA-1500 claims accurately. CD-ROM in text and accompanying workbook provides additional exercises and practice in completing HCFA-1500 claims electronically. Includes new information regarding CPT-5, ICD-10-CM and HCFA reimbursement issues

Preface

Health Insurance Specialist---Roles and Responsibilities

(8)

Employment Opportunities

(2)

... MORE

Basic Skill Requirements

(3)

Health Insurance Specialist Responsibilities

(1)

Professional Certification

(1)

Review

(1)

Legal Considerations

(12)

Breach of Confidentiality

(3)

Claims Information Telephone Queries

(2)

Facsimile Transmission

(1)

Confidentiality and the Internet

(1)

Insurance Fraud and Abuse

(2)

Review

(3)

Introduction to Health Insurance

(10)

What Is Health Insurance?

(1)

Disability and Liability Insurance

(1)

Major Developments in Health Insurance

(5)

Current Mixture of Health Insurance Plans

(1)

Third-Party Reimbursement Methods

(1)

Review

(1)

Managed Health Care

(8)

What Is Managed Health Care?

(1)

Six Managed Care Models

(3)

HMO Accreditation

(1)

Government Managed Care Ventures

(1)

Effects of Managed Care on Administrative Procedures

(1)

Review

(2)

Life Cycle of an Insurance Claim

(28)

Development of the Claim

(1)

New Patient Interview and Check-in Procedure

(9)

Established Patient Return Visit

(4)

Post Clinical Check-Out Procedures

(5)

Computerized Practice Procedure Modifications

(2)

Insurance Company Processing of a Claim

(2)

Maintaining Provider Insurance Claim Files

(2)

Review

(3)

Diagnosis Coding

(44)

ICD-9-CM

(1)

Primary Versus Principal Diagnosis

(2)

Principal Versus Secondary Procedures

(1)

Coding Qualified Diagnoses

(1)

ICD-9-CM Coding System

(3)

Disease Index Organization

(2)

Basic Steps for Using the Index

(1)

Organization of the Tabular List

(4)

Basic Steps for Using the Tabular List

(1)

Index Conventions

(4)

Tabular List Conventions

(5)

Working with Index Tables

(10)

Coding Special Disorders

102

(4)

HCFA ICD-9-CM Guidelines

106

(1)

Office Procedure Errors Contributing to Inaccurate Diagnosis Coding

107

(1)

Review

108

(3)

CPT™ Procedure Coding

111

(54)

CPT Coding System

112

(1)

CPT Format

113

(2)

CPT Symbols and Conventions

115

(6)

CPT Index

121

(2)

Basic Steps for Coding Procedures

123

(1)

Surgery Overview

124

(5)

Notes for Coding Special Surgery Cases

129

(4)

Medicine Section Overview

133

(2)

Radiology Section Overview

135

(2)

Pathology/Laboratory Section Overview

137

(2)

Evaluation and Management Services Overview

139

(12)

CPT Modifiers

151

(11)

Review

162

(3)

HCPCS Coding System

165

(14)

HCPCS Procedure Code Organization

165

(1)

HCPCS National (Level II) Codes

166

(2)

The National HCPCS Index

168

(3)

Determining Carrier Responsibility

171

(1)

Using Level II National HCPCS Codes

172

(2)

HCPCS Modifiers

174

(1)

Using HCPCS Level II Modifiers

174

(2)

Review

176

(3)

HCFA Reimbursement Issues

179

(16)

The Medicare Fee Schedule

180

(2)

HCFA Regulations

182

(2)

Medicare Reimbursement Issues

184

(5)

Correct Coding Initiative

189

(4)

Medicare Compliance Plans

193

(1)

Review

194

(1)

Coding From Source Documents

195

(26)

Applying ICD-9-CM Coding Guidelines

195

(4)

CPT/HCPCS Billing Considerations

199

(1)

Coding Clinical Scenarios

200

(4)

Coding Medical Reports

204

(6)

Coding Operative Reports

210

(11)

Essential Claim Form Instructions

221

(18)

General Billing Guidelines

222

(2)

Optical Scanning Guidelines

224

(3)

Reporting Diagnoses: ICD-9-CM Codes

227

(1)

Instructions for Line 24

228

(4)

Federal Tax ID Number

232

(1)

Reporting the Billing Entity

233

(1)

Processing Secondary Claims

234

(1)

Common Errors that Delay Processing

235

(1)

Final Processing Steps of Paper Claims

236

(1)

Maintaining Insurance Claim Files for the Practice

236

(1)

Review

237

(2)

Filing Commercial Claims

239

(22)

Insurance Program Comparison Chart

240

(1)

Step-by-Step Instructions for Primary Commercial Claims

240

(1)

Patient and Policy Identification

241

(6)

Diagnostic and Treatment Data

247

(4)

Instructions for Line 24

251

(2)

Provider/Billing Entity Identification

253

(3)

Commercial Secondary Claims

256

(3)

Guidelines for Primary and Supplemental Policy

259

(1)

Same Carrier

259

(1)

Different Carriers

259

(2)

Blue Cross and Blue Shield Plans

261

(32)

Brief History

262

(1)

BCBS Association

263

(1)

BCBS Distinctive Features

264

(1)

Participating Providers

264

(1)

Nonparticipating Providers

265

(1)

Traditional Fee-for-Service Coverage

265

(1)

Nationwide Accounts

266

(1)

Bluecard Program

267

(1)

BCBS and Managed Care

268

(3)

BCBS Health Maintenance Organization Plan

271

(1)

Medicare Supplemental Plans

271

(1)

Billing Information Summary

271

(1)

Step-by-Step Instructions---Primary BCBS Claims

272

(12)

Two BCBS Full Benefit Policies

284

(3)

BCBS Secondary Claims

287

(5)

Review

292

(1)

Medicare

293

(48)

Medicare Eligibility

294

(1)

Medicare Enrollment

295

(1)

Part A Coverage

296

(2)

Part B Coverage

298

(2)

Participating Providers

300

(1)

Nonparticipating Provider Restrictions

300

(3)

Medicare Fee Schedule (MFS)

303

(1)

Medicare as a Secondary Payor

304

(4)

Medicare Supplemental Plans

308

(3)

Medicare and Managed Care

311

(1)

Medicare---HMO Program

311

(2)

HMO Primary Plans

313

(1)

HMO Supplemental Plan

313

(1)

Medicare+Choice

313

(1)

Billing Information Notes

314

(1)

Step-by-Step Claim Form Instructions

315

(15)

Primary Medicare with a Medigap Policy

330

(2)

Medicare and NonHMO Medicaid (Medical) Claims

332

(2)

When Medicare Is the Secondary Claims Payer

334

(5)

Review

339

(2)

Medicaid

341

(24)

Federal Eligibility Requirements

344

(1)

Federal Benefits

345

(1)

State Services

346

(1)

Medicaid as a Secondary Payer

347

(1)

Participating Providers

348

(1)

Medicaid and Managed Care

348

(1)

Billing Information Notes

348

(3)

Step-by-Step Claim Form Instructions

351

(10)

Secondary Medicaid Claims

361

(2)

Review

363

(2)

Tricare/Champus

365

(30)

Tricare Overview

366

(4)

Tricare Eligibility

370

(1)

Tricare Preauthorization

371

(2)

Covered Services

373

(2)

Tricare as a Secondary Payor

375

(1)

Tricare Limiting Charges

376

(1)

Uniformed Services Retiree HMO Plan

376

(1)

Tricare Supplemental Plans

376

(1)

Tricare Billing Information

377

(2)

Tricare Primary Claim Instructions

379

(10)

Tricare as Secondary Payor Instructions

389

(3)

Review

392

(3)

Workers' Compensation

395

(26)

Federal Compensation Programs

396

(1)

State-Sponsored Coverage

396

(1)

Eligibility

397

(1)

Classification of On-the-Job Injuries

397

(2)

OSHA Act of 1970

399

(1)

Special Handling of Workers' Compensation Cases

399

(1)

Workers' Compensation and Managed Care

400

(1)

First Report of Injury

400

(3)

Progress Reports

403

(1)

Billing Information Notes

403

(3)

Workers' Compensation Claim Instructions---Patient and Policy Identification

406

(4)

Diagnostic and Treatment Data

410

(5)

Provider/Billing Entity Identification

415

(4)

Review

419

(2)

Appendix I Case Study Set One

421

(16)

Appendix II Clinic Billing Manual and Case Studies

437

(38)

Appendix III Forms

475

(6)

Appendix IV Answers to Coding Exercises

481

(10)

Appendix V Bibliography

491

(4)

Glossary

495

(28)

Index

523

RENT TEXTBOOKS

Understanding Health Insurance : A Guide to Professional Billing

Why Rent from Knetbooks?

Top 5 reasons to order all your textbooks from Knetbooks:

Related Products