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Health Insurance Today: A Practical Approach 4th Revised edition [Pehme köide]

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  • Formaat: Paperback / softback, 512 pages, kõrgus x laius: 276x216 mm, Approx. 189 illustrations (189 in full color)
  • Ilmumisaeg: 24-Sep-2012
  • Kirjastus: Saunders
  • ISBN-10: 1455708194
  • ISBN-13: 9781455708192
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Health Insurance Today: A Practical Approach 4th Revised editionSuurem pilt
  • Formaat: Paperback / softback, 512 pages, kõrgus x laius: 276x216 mm, Approx. 189 illustrations (189 in full color)
  • Ilmumisaeg: 24-Sep-2012
  • Kirjastus: Saunders
  • ISBN-10: 1455708194
  • ISBN-13: 9781455708192
Teised raamatud teemal:
Püsilink: https://www.kriso.ee/db/9781455708192.html
Märksõnad:
Learn to complete and submit clean claim forms for major insurance carriers. Health Insurance Today, 3rd Edition, provides case studies for each of the chapters covering these major payers so you can learn how to abstract the information from the patient's chart to complete the CMS-1500. You will learn to complete and submit paper claims, but the emphasis is on electronic claims filing, keeping you up-to-date on HIPAA, electronic health records, and the latest industry standards. Select exercises on the companion Evolve Resource site let you gain experience entering information into a practice management program; producing an electronic CMS-1500; and submitting a claim electronically.





Clear, attainable learning objectives help you focus on the most important information.











What Did You Learn? review questions allow you to ensure you understand the material already presented before moving on to the next section.











Direct, conversational writing style makes reading fun and concepts easier to understand.











Imagine This! scenarios help you understand how information in the book applies to real-life situations.











Stop and Think exercises challenge you to use your critical thinking skills to solve a problem or answer a question.











HIPAA Tips emphasize the importance of privacy and following government rules and regulations.











Chapter summaries relate to learning objectives, provide a thorough review of key content, and allow you to quickly find information for further review.

















Key coverage of new topics includes medical identity theft and prevention, National Quality Forum (NQF) patient safety measures, ACSX12 Version 5010 HIPAA transaction standards, EMS rule on mandatory electronic claims submission, and standards and implementation specifications for electronic health record technology.





Increased emphasis on producing and submitting claims electronically gives you an edge in today's competitive job market.





UPDATED! Additional ICD-10 coding content prepares you for the upcoming switch to the new coding system.





NEW! Content on ARRA, HI-TECH, and the Health Insurance Reform Act ensures you are familiar with the latest health care legislation and how it impacts what you do on the job.
UNIT I BUILDING A FOUNDATION
Chapter 1 The Origins of Health Insurance
What Is Insurance?
1(2)
History
3(1)
Metamorphosis of Medical Insurance
4(3)
Key Health Insurance Issues
7(3)
How Can People Obtain Health Insurance?
7(1)
Access to Health Insurance
7(2)
What Affects the Cost of Healthcare?
9(1)
Cost Sharing
10(1)
How Much is Enough?
10(1)
Health Insurance Plans
10(3)
Chapter 2 Tools of the Trade: A Career as a Health (Medical) Insurance Professional
Your Future as a Health Insurance Professional
13(4)
Required Skills and Interests
14(3)
Job Duties and Responsibilities
17(1)
Career Prospects
18(2)
Occupational Trends and Future Outlook
18(1)
What to Expect as a Health Insurance Professional
19(1)
Rewards
20(1)
Is a Career in Healthcare Right for You?
20(1)
Certification Possibilities
20(1)
Career Focus for the Health Insurance Professional
21(1)
Electronic Claims
21(1)
CMS-1500 (08/05) Paper Form
21(5)
Chapter 3 The Legal and Ethical Side of Medical Insurance
Medical Law and Liability
26(1)
Employer Liability
27(1)
Employee Liability
27(1)
Insurance and Contract Law
27(1)
Elements of a Legal Contract
27(1)
Termination of Contracts
28(1)
Medical Law and Ethics Applicable to Health Insurance
28(1)
Important Legislation Affecting Health Insurance
29(1)
Federal Privacy Act of 1974
29(1)
Federal Omnibus Budget Reconciliation Act of 1980
29(1)
Tax Equity and Fiscal Responsibility Act of 1982
29(1)
Consolidated Omnibus Budget Reconciliation Act of 1986
29(1)
Federal False Claim Amendments Act of 1986
30(1)
Fraud and Abuse Act
30(1)
Federal Omnibus Budget Reconciliation Act of 1987
30(1)
The Patient Protection and Affordable Care Act
30(1)
Medical Ethics and Medical Etiquette
30(2)
Medical Ethics
30(1)
Medical Etiquette
31(1)
Medical Record
32(1)
Purposes of a Medical Record
32(1)
Complete Medical Record
32(1)
Who Owns Medical Records?
32(1)
Retention of Medical Records
32(1)
Access to Medical Records
33(1)
Releasing Medical Record Information
33(1)
Documentation of Patient Medical Record
33(3)
Health Insurance Portability and Accountability Act and Compliance
36(3)
Impact of Health Insurance Portability and Accountability Act
37(1)
Enforcement of Confidentiality Regulations of Health Insurance Portability and Accountability Act
38(1)
Developing a Compliance Plan
38(1)
Confidentiality and Privacy
39(2)
Confidentiality
39(1)
Privacy
39(1)
Security
39(1)
Exceptions to Confidentiality
40(1)
Authorization to Release Information
40(1)
Exceptions for Signed Released of Information for Insurance Claims Submission
40(1)
Breach of Confidentiality
41(1)
Healthcare Fraud and Abuse
41(5)
Defining Fraud and Abuse
41(1)
Preventing Fraud and Abuse
42(4)
Chapter 4 Types and Sources of Health Insurance Types of Health Insurance
46(16)
Indemnity (Fee-for-Service)
46(2)
Managed Care
47(1)
Sources of Health Insurance
47(1)
Group Contract
48(1)
Individual Policies
48(1)
Medicare
48(1)
Medicaid
48(1)
Tricare/Champva
48(2)
Standardized Benefits and Coverage Rule
49(1)
Disability Insurance
49(1)
Miscellaneous Healthcare Coverage Options
50(3)
Medical Savings Account
50(1)
Flexible Spending Account
50(1)
Health Reimbursement Arrangements
51(1)
Health Insurance Exchanges
52(1)
Accountable Care Organizations (ACOs)
52(1)
Long-Term Care Insurance
52(1)
Dental Care
53(1)
Vision Care
53(1)
Consolidated Omnibus Budget Reconciliation Act
53(1)
Health Insurance "Watchdogs"
54(1)
Other Terms Common to Third-Party Carriers
54(8)
Birthday Rule
54(1)
Coordination of Benefits
55(1)
Medical Necessity
55(1)
Usual, Reasonable, and Customary
55(3)
Participating Versus Nonparticipating Providers
58(1)
Miscellaneous Terms
58(4)
UNIT II HEALTH INSURANCE BASICS
Chapter 5 Claim Submission Methods
Overview of the Health Insurance Claims Process
62(1)
Two Basic Claims Submission Methods
62(1)
Proposed Revisions to the CMS-1500 (08-05) Form
63(1)
Electronic Claims
63(1)
Health Insurance Portability and Accountability Act
63(2)
Electronic Transactions and Code Set Requirements
64(1)
Privacy Requirements
64(1)
Security Requirements
64(1)
National Identifier Requirements
64(1)
The New HIPAA 5010 Standards
65(1)
The Electronic Insurance Claims Process
66(9)
Essential Information for Claims Processing
66(7)
Verifying Insurance with New Technology
73(2)
Advantages of Electronic Claims
75(1)
Two Ways to Submit Electronic Claims
75(2)
Claims Clearinghouses
75(1)
Direct Claims
76(1)
Clearinghouses Versus Direct
76(1)
The Universal Claim Form (CMS-1500)
77(8)
Format of the Form
77(1)
Optical Character Recognition
77(1)
Who Uses the Paper Form?
78(1)
Proofreading
79(1)
Claim Attachments
79(1)
Tracking Claims
80(5)
Chapter 6 Traditional Fee-for-Service/Private Plans
Traditional Fee-for-Service/Indemnity Insurance
85(1)
How a Fee-for-Service Plan Works
86(1)
Health Care Reform and Preexisting Conditions
87(1)
HIPAA and Credible Coverage
88(1)
Commercial or Private Health Insurance
88(2)
Who Pays for Commercial Insurance?
88(1)
High-Risk Pool
88(1)
Coverage Mandate 2014
89(1)
Health Insurance Exchange
89(1)
What Is Self-Insurance?
89(1)
Blue Cross and Blue Shield
90(5)
History of Blue Cross
90(1)
History of Blue Shield
90(1)
Blue Cross and Blue Shield Programs
91(4)
Participating Versus Nonparticipating Providers
95(1)
Submitting BCBS and Commercial Claims
95(1)
Timely Filing
95(1)
Filing Electronic Claims
95(1)
Commercial Claims Involving Secondary Coverage
96(6)
Electronic Remittance Advice (ERA)
96(6)
Chapter 7 Unraveling the Mysteries of Managed Care
What Is Managed Care?
102(1)
Common Types of Managed Care Organizations
103(3)
Preferred Provider Organization
104(1)
Health Maintenance Organization
105(1)
Other Types of MCOs
106(1)
Advantages and Disadvantages of Managed Care
106(1)
Advantages
106(1)
Disadvantages
106(1)
Managed Care Certification and Regulation
107(1)
National Committee on Quality Assurance
107(1)
National Committee on Quality Assurance; Health Insurance Portability and Accountability Act
107(1)
The Joint Commission
107(1)
URAC
107(1)
Utilization Review
108(1)
Complaint Management
108(1)
Preauthorization, Precertification, Predetermination, and Referrals
108(4)
Preauthorization
109(1)
Precertification
109(1)
Predetermination
109(1)
Referrals
109(3)
Health Insurance Portability and Accountability Act and Managed Care
112(3)
Impact of Managed Care
115(1)
Impact of Managed Care on the Physician-Patient Relationship
115(1)
Impact of Managed Care on Healthcare Providers
115(1)
Healthcare Reform's Impact on MCOs
116(1)
Future of Managed Care
116(4)
Chapter 8 Understanding Medicaid
What Is Medicaid?
120(1)
Evolution of Medicaid
121(2)
Temporary Assistance for Needy Families
121(1)
Supplemental Security Income
121(2)
Medicaid and Healthcare Reform
123(1)
Structure of Medicaid
123(4)
Federal Government's Role
123(1)
Mandated Services
123(1)
States' Options
124(1)
Community First Choice Option
125(1)
State Children's Health Insurance Program
125(1)
Fiscal Intermediaries/Medicaid Contractors
126(1)
Medicaid Integrity Contractors
126(1)
Other Medicaid Programs
127(1)
Maternal and Child Health Services
127(1)
Early and Periodic Screening, Diagnosis, and Treatment Program
127(1)
Program of All-inclusive Care for the Elderly
127(1)
Medicaid Home and Community-Based Services Waivers
127(1)
Premiums and Cost Sharing
128(1)
Nonemergency Use of the Emergency Department
129(1)
Emergency Medical Treatment & Labor Act
129(1)
Payment for Medicaid Services
129(1)
Medically Necessary
129(1)
Prescription Drug Coverage
129(1)
Dual Eligibles
129(1)
Accepting Medicaid Patients
130(1)
Participating Providers
130(1)
Verifying Medicaid Eligibility
130(2)
Medicaid Identification Card
131(1)
Automated Voice Response System
131(1)
Electronic Data Interchange
132(1)
Point-of-Sale Device
132(1)
Computer Software Program
132(1)
Benefits of Eligibility Verification Systems
132(1)
Medicare/Medicaid Relationship
132(1)
Special Medicare/Medicaid Programs
132(1)
Medicare and Medicaid Differences Explained
133(1)
Medicaid Managed Care
133(1)
Medicaid Claims
134(1)
Completing the CMS-1500 Using Medicaid Guidelines
134(1)
Medicaid Secondary Claims
134(1)
Resubmission of Medicaid Claims
134(1)
Reciprocity
134(1)
Medicaid and Third-Party Liability
135(1)
Common Medicaid Billing Errors
135(1)
Medicaid Remittance Advice
136(1)
Special Billing Notes
136(3)
Time Limit for Filing Medicaid Claims
136(1)
Copayments
136(2)
Accepting Assignment
138(1)
Services Requiring Prior Approval
138(1)
Preauthorization
138(1)
Retention, Storage, and Disposal of Records
138(1)
Fraud and Abuse in the Medicaid System
139(1)
What Is Medicaid Fraud?
139(1)
Patient Abuse and Neglect
139(1)
Medicaid Quality Practices
140(4)
Chapter 9 Conquering Medicare's Challenges
Medicare Program
144(9)
Medicare Program Structure
145(5)
Enrollment
150(1)
Premiums and Cost-Sharing Requirements
150(1)
Medicare Part C (Medicare Advantage Plans)
151(1)
Other Medicare Health Plans
151(1)
Medicare Part D (Medicare Prescription Drug Benefit Plan)
152(1)
Changing Medicare Health or Prescription Drug Coverage
152(1)
Programs of All-Inclusive Care for the Elderly (PACE)
152(1)
Medicare Combination Coverages
153(2)
Medicare/Medicaid Dual Eligibility
153(1)
Medicare Supplement Policies
153(2)
Medicare and Managed Care
155(5)
Medicare HMOs
155(3)
Advantages and Disadvantages of Medicare HMOs
158(2)
Why This Information Is Important to the Health Insurance Professional
160(1)
Preparing for the Medicare Patient
160(4)
Medicare's Lifetime Release of Information Form
160(1)
Determining Medical Necessity
160(1)
Advanced Beneficiary Notice
161(1)
Local Coverage Determination (LCD)
162(1)
Health Insurance Claim Number and Identification Card
162(1)
Replacing the Medicare Card
162(2)
Medicare Billing
164(1)
Physician Fee Schedule
164(1)
Medicare Participating and Nonparticipating Providers
165(1)
Determining What Fee to Charge
165(1)
Filing Medicare Claims
165(3)
Electronic Claims
165(1)
Administrative Simplification Compliance Act (ASCA)
165(2)
Transition to ASC X12 Version 5010
167(1)
Exceptions to Mandatory Electronic Claim Submission
167(1)
Small Providers and Full-Time Equivalent (FTE) Employee Assessments
167(1)
ASCA Enforcement of Paper Claim Submission
167(1)
Deadline for Filing Medicare Claims
168(1)
Using the CMS-1500 Form for Medicare Claims
168(4)
CMS-1500 Completion Guidelines
168(1)
Completing a Medigap Claim
169(1)
Medicare Secondary Payer
169(2)
Medigap Crossover Program
171(1)
Medicare/Medicaid Crossover Claims
171(1)
Medicare Summary Notice
172(3)
Information Contained on the MSN
172(1)
Medicare Remittance Advice
172(3)
Electronic Funds Transfer
175(1)
Medicare Audits and Appeals
175(5)
Audits
175(1)
Recovery Audit Contractor (RAC) Program
176(1)
Appeals (Fee-for-Service Claims)
176(3)
Appeals Process (Medicare Managed Care Claims)
179(1)
Quality Review Studies
180(7)
Quality Improvement Organizations
181(1)
Beneficiary Notices Initiative
181(1)
Beneficiary Complaint Response Program
181(1)
Hospital-Issued Notice of Noncoverage (HINN) and Notice of Discharge (NODMAR) and Medicare Appeal Rights Reviews
181(1)
The Center for Medicare and Medicaid Innovation (CMI)
182(1)
Physician Review of Medical Records
182(1)
Physician Quality Reporting System (PQRS)
182(1)
Medicare Billing Fraud
182(1)
Clinical Laboratory Improvement Amendments Program
182(5)
Chapter 10 Military Carriers
Military Health Programs
187(1)
Tricare
187(3)
Military Health System
188(1)
Tricare Management Activity (TMA)
188(1)
Tricare Regional Contractors
188(1)
Who is Eligible for Tricare?
188(1)
Who Is Not Eligible for Tricare?
189(1)
Losing Tricare Eligibility
189(1)
Tricare Program Options
189(1)
Tricare Overseas Program (TOP)
189(1)
Tricare Young Adult (TYA) Program
189(1)
What Tricare Pays
190(1)
Tricare's Additional Programs
190(4)
Tricare Dental Programs
190(3)
Supplemental Tricare Programs
193(1)
Tricare and Other Health Insurance (OHI)
193(1)
Tricare Standard Supplemental Insurance
193(1)
Tricare For Life
193(1)
Verifying Tricare Eligibility
194(1)
Tricare-Authorized Providers
194(2)
Tricare PARs and nonPARs
196(1)
Cost Sharing
196(1)
Tricare Coding and Payment System
196(1)
Tricare Claims Processing
197(2)
Who Submits Claims
197(1)
Submitting Paper Claims
198(1)
Deadline for Submitting Claims
199(1)
Tricare Explanation of Benefits
199(1)
Champva
199(8)
Extending Eligibility
202(1)
Identifying Champva-Eligible Beneficiaries
202(1)
Champva Benefits
203(1)
Champva Cost Sharing
203(2)
Prescription Drug Benefit
205(1)
Champva In-house Treatment Initiative (CIT)
206(1)
Champva-Tricare Connection
206(1)
Champva-Medicare Connection
206(1)
Champva and HMO Coverage
206(1)
Champva Providers
206(1)
Champva For Life (CFL)
207(1)
Filing Champva Claims
207(1)
Champva Preauthorization Requirements
207(1)
Champva Claims Filing Deadlines
208(1)
Instructions for Completing Tricare/Champva Paper Claim Forms
208(1)
Claims Filing Summary
209(1)
Champva Explanation of Benefits
209(1)
Claims Appeals and Reconsiderations
209(1)
HIPAA and Military Insurers
209(5)
Chapter 11 Miscellaneous Carriers: Workers' Compensation and Disability Insurance
Workers' Compensation
214(10)
History
214(1)
Federal Legislation and Workers' Compensation
215(1)
Eligibility
215(2)
Workers' Compensation Claims Process
217(5)
Special Billing Notes
222(2)
Workers' Compensation and Managed Care
224(1)
Health Insurance Portability and Accountability Act and Workers' Compensation
224(1)
Workers' Compensation Fraud
224(1)
Online Workers' Compensation Service Center
224(1)
Private and Employer-Sponsored Disability Income Insurance
224(6)
Defining Disability
225(1)
Disability Claims Process
225(5)
Federal Disability Programs
230(9)
Americans with Disabilities Act
231(1)
Social Security Disability Insurance
231(1)
Supplemental Security Income
232(1)
State Disability Programs
232(1)
Centers for Disease Control and Prevention Disability and Health Team
232(1)
Ticket to Work Program
233(1)
Filing Supplemental Security Income and Social Security Disability Insurance Claims
233(6)
UNIT III CRACKING THE CODES
Chapter 12 Diagnostic Coding
Introduction to International Classification of Diseases Coding System
239(1)
Three Major Coding Structures
239(1)
History of International Classification of Diseases Coding
240(1)
Uses of Coded Data
240(1)
Two Diagnostic Coding Systems
241(1)
Comparing the Two Systems
241(1)
Guidelines
241(1)
ICD-9-CM Coding Manual
242(4)
Volume 2, Alphabetic List (Index)
242(1)
Three Sections of Volume 2
243(3)
National Coverage Determinations and Local Coverage Determinations
246(1)
Process of Classifying Diseases
246(3)
Volume 1, Tabular List
248(1)
Supplementary Sections of Volume 1
248(1)
Locating a Code in the Tabular List (Volume 1)
249(1)
Symbols and Conventions Used in Volume 1
249(1)
Typefaces
250(1)
Instructional Notes
250(1)
Essential Steps to Diagnostic Coding
250(1)
Special Coding Situations
250(3)
Coding Signs and Symptoms
250(1)
Etiology and Manifestation Coding
251(1)
Combination Codes
252(1)
Coding Late Effects
252(1)
Coding Neoplasms
252(1)
Coding Hypertension
253(1)
Overview of ICD-10 Coding System
253(4)
ICD-10-CM Code Structure
253(1)
Format of ICD-10-CM Manual
253(4)
Coding Steps for Alphabetic Index
257(1)
Tabular List
258(6)
Format and Structure of Codes
258(1)
Tabular List Conventions
259(4)
Manifestation Codes
263(1)
Morphology Codes
263(1)
Default Codes
264(1)
ICD-10-CM General Coding Guidelines and
Chapter-Specific Guidelines
264(1)
Codes from A00.0 through T88.9, Z00-Z99.89
264(1)
Diagnostic Coding and Reporting Guidelines for Outpatient Services
265(2)
Selection of First-Listed Condition
266(1)
Outpatient Surgery
266(1)
Observation Stay
266(1)
Codes That Describe Symptoms and Signs
266(1)
Encounters for Circumstances Other than a Disease or Injury
266(1)
Level of Detail in Coding
266(1)
Code for Diagnosis, Condition, Problem, or Other Reason for Encounter/Visit
266(1)
Code All Documented Conditions That Coexist
266(1)
Health Insurance Portability and Accountability Act and Coding
267(1)
Code Sets Adopted as Health Insurance Portability and Accountability Act Standards
268(1)
Implementation of ICD-10
268(1)
Importance of Learning Both Diagnostic Coding Systems
268(5)
Chapter 13 Procedural, Evaluation and Management, and HCPCS Coding
Overview of Current Procedural Terminology (CPT) Coding
273(1)
Purpose of CPT
274(1)
Development of CPT
274(1)
Three Levels of Procedural Coding
274(1)
CPT Manual Format
275(4)
Introduction and Main Sections
275(1)
Category II Codes
275(1)
Category III Codes
276(1)
Appendices A through N
276(1)
CPT Index
277(1)
Symbols Used in CPT
277(1)
Modifiers
278(1)
Unlisted Procedure or Service
278(1)
Special Reports
278(1)
Conventions and Punctuation Used in CPT
279(1)
Importance of the Semicolon
279(1)
Section, Subsection, Subheading, and Category
279(1)
Cross-Referencing with See
279(1)
Basic Steps of CPT Coding
279(2)
Evaluation and Management (E & M) Coding
281(5)
Vocabulary Used in E & M Coding
281(2)
Documentation Requirements
283(1)
Three Factors to Consider
283(1)
Key Components
284(1)
Contributing Factors
284(2)
Prolonged Services
286(1)
Subheadings of Main E & M Section
286(2)
Office or Other Outpatient Services
286(1)
Hospital Observation Services
286(1)
Hospital Inpatient Services
287(1)
Consultations
287(1)
Emergency Department Services
288(1)
Critical Care Services
288(1)
Nursing Facility Services
288(1)
E & M Modifiers
288(1)
Importance of Documentation
289(1)
E & M Documentation Guidelines: 1995 versus 1997
289(1)
Deciding Which Guidelines to Use
289(1)
Overview of HCFA Common Procedure Coding System (HCPCS)
289(2)
HCPCS Level II Manual
290(1)
Modifiers
291(1)
Appendices
291(1)
National Correct Coding Initiative (NCCI)
291(1)
Health Insurance Portability and Accountability Act (HIPAA) and HCPCS Coding
292(1)
Crosswalk
292(1)
Current Procedural Terminology, 5th Edition (CPT-5)
292(4)
UNIT IV THE CLAIMS PROCESS
Chapter 14 The Patient
Patient Expectations
296(3)
Professional Office Setting
297(1)
Relevant Paperwork and Questions
297(1)
Honoring Appointment Times
297(1)
Patient Load
298(1)
Getting Comfortable with the Healthcare Provider
298(1)
Privacy and Confidentiality
298(1)
Financial Issues
298(1)
Future Trends
299(1)
Aging Population
299(1)
Internet as a Healthcare Tool
299(1)
Patients as Consumers
299(1)
Health Insurance Portability and Accountability Act (HIPAA) Requirements
299(4)
Authorization to Release Information
300(1)
HIPAA and Covered Entities
300(1)
HIPAA Requirements for Covered Entities
300(1)
Patient's Right of Access and Correction
301(1)
Accessing Information through Patient Authorization
301(1)
Accessing Information through De-identification
301(2)
Billing Policies and Practices
303(5)
Assignment of Benefits
303(1)
Keeping Patients Informed
304(1)
Accounting Methods
304(2)
Electronic Medical Records
306(2)
Billing and Collection
308(3)
Billing Cycle
308(1)
Arranging Credit or Payment Plans
308(2)
Problem Patients
310(1)
Laws Affecting Credit and Collection
311(1)
Truth in Lending Act
311(1)
Fair Credit Billing Act
311(1)
Equal Credit Opportunity Act
311(1)
Fair Credit Reporting Act
311(1)
Fair Debt Collection Practices Act
311(1)
Collection Methods
312(2)
Collection by Telephone
312(1)
Collection by Letter
313(1)
Billing Services
314(1)
Collection Agencies
314(1)
Small Claims Litigation
314(5)
Who Can Use Small Claims
315(1)
How the Small Claims Process Works
315(4)
Chapter 15 The Claim
Introduction
319(1)
General Guidelines for Completing CMS-1500 Form
319(1)
Keys to Successful Claims
319(4)
First Key: Collect and Verify Patient Information
320(1)
Second Key: Obtain Necessary Preauthorization and Precertification
321(1)
Third Key: Documentation
322(1)
Fourth Key: Follow Payer Guidelines
322(1)
Fifth Key: Proofread Claim to Avoid Errors
322(1)
Sixth Key: Submit a Clean Claim
322(1)
Rejected Claims versus Denied Claims
323(1)
Health Insurance Portability and Accountability Act (HIPAA) and National Standard Employer Identifier Number
323(1)
Claim Process
323(10)
Step One: Claim Is Received
325(1)
Step Two: Claims Adjudication
325(1)
Step Three: Tracking Claims
325(3)
Step Four: Receiving Payment
328(1)
Step Five: Interpreting Explanation of Benefits
328(2)
Step Six: Posting Payments
330(1)
Time Limits
330(3)
Processing Secondary Claims
333(1)
Real-Time Claims Adjudication
334(1)
Appeals
334(4)
Incorrect Payments
334(1)
Denied Claims
334(1)
Appealing a Medicare Claim
335(3)
UNIT V ADVANCED APPLICATION
Chapter 16 The Role of Computers in Health Insurance
Introduction
338(1)
Impact of Computers on Health Insurance
338(1)
Role of Health Insurance Portability and Accountability Act (HIPAA) in Electronic Transmissions
338(1)
Electronic Data Interchange
339(1)
History of Electronic Data Interchange
339(1)
Benefits of Electronic Data Interchange
339(1)
Electronic Claims Process
340(2)
Methods Available for Filing Claims Electronically
340(1)
Enrollment
340(1)
Electronic Claims Clearinghouse
340(1)
Direct Data Entry Claims
341(1)
Clearinghouse versus Direct
341(1)
Advantages of Filing Claims Electronically
342(1)
Medicare and Electronic Claims Submission
342(1)
Additional Electronic Services Available
343(1)
Electronic Funds Transfer
343(1)
Electronic Remittance Advice
344(1)
Role of Computers in Transitioning to ICD-10 Diagnostic Coding System
344(1)
Electronic Medical Record
344(8)
Combination Records
347(1)
Digital Imaging Hybrid
347(1)
Potential Issues
347(1)
Future of Electronic Medical Records
348(1)
Privacy Concerns of Electronic Medical Records
348(1)
Federal Funding for Electronic Medical Record Trials and "Meaningful Use"
348(4)
Chapter 17 Reimbursement Procedures: Getting Paid
Understanding Reimbursement Systems
352(2)
Types of Reimbursement
353(1)
Medicare and Reimbursement
354(2)
Medicare Prospective Payment System
354(1)
How the Medicare Prospective Payment System Works
355(1)
Other Systems for Determining Reimbursement
356(3)
Relative Value Scale
356(1)
Resource-Based Relative Value Scale
356(1)
Diagnosis-Related Groups
357(1)
Ambulatory Payment Classifications
358(1)
Resource Utilization Groups
358(1)
Transition of Medicare to Resource-Based Relative Value Scale
359(1)
Setting Medicare Payment Policy
359(1)
Medicare Inpatient Hospital Prospective Payment System
359(1)
Medicare Long-Term Care Hospital Prospective Payment System
359(1)
Additional Prospective Payment Systems
360(1)
Home Health Prospective Payment System
360(1)
Inpatient Rehabilitation Facility Prospective Payment System
360(1)
Significance of Reimbursement Systems to the Health Insurance Professional
360(1)
Peer Review Organizations and Prospective Payment Systems
361(1)
Understanding Computerized Patient Accounting Systems
361(4)
Selecting the Right Billing System
361(1)
Managing Transactions
362(2)
Generating Reports
364(1)
Health Insurance Portability and Accountability Act and Practice Management software
365(9)
Chapter 18 Hospital Billing and the UB-04
Hospital Versus Physician Office Billing and Coding
374(1)
Modern Hospital and Health Systems
374(1)
Emerging Issues
374(1)
Common Healthcare Facilities
375(2)
Acute Care Facilities
375(1)
Critical Access Hospitals
375(1)
Ambulatory Surgery Centers
376(1)
Other Types of Healthcare Facilities
376(1)
Legal and Regulatory Environment
377(4)
Accreditation
378(1)
Professional Standards
379(1)
Governance
379(1)
Confidentiality and Privacy
379(1)
Fair Treatment of Patients
380(1)
Common Hospital Payers and Their Claims Guidelines
381(3)
Medicare
381(2)
Medicaid
383(1)
Tricare
383(1)
Champva
383(1)
Blue Cross and Blue Shield
384(1)
Private Insurers
384(1)
National Uniform Billing Committee and the UB-04
384(3)
UB-04 Data Specifications
385(1)
8371: Electronic Version of the UB-04 Form
385(2)
Structure and Content of the Hospital Health Record
387(1)
Standards in Hospital Electronic Medical Records
388(1)
Standard Codes and Terminology
388(1)
Inpatient Hospital/Facility Coding
388(5)
ICD-9-CM (Volume 3) Codes for Inpatient Hospital Procedures
389(1)
Code Sets Used for Inpatient Hospital/Facility Claims in ICD-10-PCS
389(3)
National Correct Coding Initiative
392(1)
Recent Rule Changes Affecting Hospital Billing
393(1)
Outpatient Hospital Coding
393(1)
Hospital Outpatient Prospective Payment System
393(1)
Ambulatory Payment Classification Coding
394(1)
The Hospital Billing Process: Understanding the Basics
394(4)
Informed Consent
394(2)
Present on Admission (POA)
396(1)
Hospital Charges
396(1)
Electronic Claims Submission (ECS)
396(1)
Health Information Management (HIM) Systems
397(1)
Payment Management
397(1)
HIPAA-Hospital Connection
398(1)
Billing Compliance
398(1)
Career Opportunities in Hospital Billing
399(5)
Training, Other Qualifications, and Advancement
399(1)
Job Outlook
400(4)
Appendix A Sample Blank CMS-1500 (08/05) 404(2)
Appendix B CMS-1500 Claim Forms and Completion Instructions 406(19)
Appendix C UB-04 Claim Form and Completion Instructions 425(5)
Glossary 430