Lecture Medical assisting: Administrative and clinical competencies (2/e) - Chapter 15

Chapter 15 - Processing health care claims. This chapter also gives you the information you need about patients' financial responsibilities for services so that you can figure out how much patients should pay and how much will be billed to their health-care plans. | Medical Assisting Chapter 15 PowerPoint® to accompany Second Edition Ramutkowski • Booth • Pugh • Thompson • Whicker Chapter 15 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Processing Health Care Claims Objectives 15-1 List the basic steps of the health insurance claim process. 15-2 Describe your role in insurance claims processing. 15-3 Explain how payers set fees. 15-4 Define Medicare and Medicaid. 15-5 Discuss TRICARE and CHAMPVA healthcare benefits programs. 15-6 Distinguish between HMOs and PPOs. Processing Healthcare Claims Objectives (cont.) 15-7 Explain how to manage a workers’ compensation case. 15-8 Apply rules related to coordination of benefits. 15-9 Describe the healthcare claim preparation process. 15-10 Complete a Centers for Medicare and Medicaid service (CMS-1500) claim form. 15-11 Identify three ways to transmit electronic claims. Basic Insurance Terminology Medical insurance (health insurance) is a written | Medical Assisting Chapter 15 PowerPoint® to accompany Second Edition Ramutkowski • Booth • Pugh • Thompson • Whicker Chapter 15 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Processing Health Care Claims Objectives 15-1 List the basic steps of the health insurance claim process. 15-2 Describe your role in insurance claims processing. 15-3 Explain how payers set fees. 15-4 Define Medicare and Medicaid. 15-5 Discuss TRICARE and CHAMPVA healthcare benefits programs. 15-6 Distinguish between HMOs and PPOs. Processing Healthcare Claims Objectives (cont.) 15-7 Explain how to manage a workers’ compensation case. 15-8 Apply rules related to coordination of benefits. 15-9 Describe the healthcare claim preparation process. 15-10 Complete a Centers for Medicare and Medicaid service (CMS-1500) claim form. 15-11 Identify three ways to transmit electronic claims. Basic Insurance Terminology Medical insurance (health insurance) is a written contract policy between a policy holder and a health plan. Terms To Know premium Amount of money paid by the policy holder to the insurance carrier. benefits Medical services provided. First Party The patient policy holder. Second Party The physician who provides medical services. Third Party The health plan. Deductible - a fixed dollar amount that must be paid or met once a year before third-party payers begin to cover expenses. Coinsurance - a fixed percentage of coverage charges after the deductible is met. Co-payment - a small fee that is collected at the time of the visit. Exclusions - uncovered expenses. Formulary - an approved list of drugs. Basic Insurance Terminology (cont.) Liability Insurance Covers injuries caused by the insured or on their property. Disability Insurance Insurance that is activated when the insured is injured or disabled. Basic Insurance Terminology (cont.) Types of Health Plans Fee For Service Plans Managed Care Plans Oldest and most expensive

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