AHEA 113 - Medical Insurance & Coding

2.5 Credit: (2 lecture, 1 lab, 0 clinical) 3 Contact Hours: [Pre- or co-requisite: AHEA 215 ]

Insurance claim forms for a physician’s office, diagnostic and procedural coding, major sources of health insurance and their billing requirements, and the larger picture of health care financing will be covered in this course. Students will generate forms for Blue Shield, Medicare, Medicaid, and commercial carriers. Emphasis is placed on the use of billing reference manuals and coding books to accurately verify insurance company rules for billing.
Semesters Offered: fall semesters

Course Goals/ Objectives/ Competencies:

Explain Third Party Reimbursement
VIII.C.1	Identify:
	a.	types of third party plans
	b.	information required to file a third party claim
	c.	the steps for filing a third party plan
VIII.C.2	Outline managed care requirements for patient referral
VIII.C.3	Describe processes for:
	a.	verification of eligibility for services
	b.	precertification
	c.	preauthorization
VIII.C.4	Define a patient-centered medical home (PCMH)
VIII.C.5	Differentiate between fraud and abuse
VIII.P.1	Interpret information on an insurance card
VIII.P.2	Verify eligibility for services including documentation
VIII.P.3	Obtain precertification or preauthorization including documentation
VIII.P.4	Complete an insurance claim form
VIII.A.1	Interact professionally with third party representatives
VIII.A.2	Display tactful behavior when communicating with medical providers regarding third party requirements
VIII.A.3	Show sensitivity when communicating with patients regrading third party requirements

Explain Procedural and Diagnostic Coding
IX.C.1	Describe how to use the most current procedural coding system
IX.C.2	Describe how to use the most current diagnostic coding classification system
IX.C.3	Describe how to use the most current HCPCS level II coding system
IX.C.4	Discuss the effects of:
	a.	upcoding
	b.	downcoding
IX.C.5	Define medical necessity as it applies to procedural and diagnostic coding
IX.P.1	Perform procedural coding
IX.P.2	Perform diagnostic coding
IX.P.3	Utilize medical necessity guidelines
IX.A.1	Utilize tactful communication skills with medical providers to ensure accurate code selection

Taken from the 2015 Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting