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Understanding Health Insurance : A Guide to Professional Billing,9780766813083
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Understanding Health Insurance : A Guide to Professional Billing

by
Edition:
5th
ISBN13:

9780766813083

ISBN10:
0766813088
Media:
Paperback
Pub. Date:
11/1/1999
Publisher(s):
Thomson Learning
List Price: $73.45

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This is the 5th edition with a publication date of 11/1/1999.
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Summary

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

Table of Contents

Preface xi
Health Insurance Specialist---Roles and Responsibilities
1(8)
Employment Opportunities
1(2)
Basic Skill Requirements
3(3)
Health Insurance Specialist Responsibilities
6(1)
Professional Certification
7(1)
Review
8(1)
Legal Considerations
9(12)
Breach of Confidentiality
10(3)
Claims Information Telephone Queries
13(2)
Facsimile Transmission
15(1)
Confidentiality and the Internet
16(1)
Insurance Fraud and Abuse
16(2)
Review
18(3)
Introduction to Health Insurance
21(10)
What Is Health Insurance?
21(1)
Disability and Liability Insurance
22(1)
Major Developments in Health Insurance
23(5)
Current Mixture of Health Insurance Plans
28(1)
Third-Party Reimbursement Methods
29(1)
Review
30(1)
Managed Health Care
31(8)
What Is Managed Health Care?
31(1)
Six Managed Care Models
32(3)
HMO Accreditation
35(1)
Government Managed Care Ventures
36(1)
Effects of Managed Care on Administrative Procedures
36(1)
Review
37(2)
Life Cycle of an Insurance Claim
39(28)
Development of the Claim
40(1)
New Patient Interview and Check-in Procedure
40(9)
Established Patient Return Visit
49(4)
Post Clinical Check-Out Procedures
53(5)
Computerized Practice Procedure Modifications
58(2)
Insurance Company Processing of a Claim
60(2)
Maintaining Provider Insurance Claim Files
62(2)
Review
64(3)
Diagnosis Coding
67(44)
ICD-9-CM
68(1)
Primary Versus Principal Diagnosis
69(2)
Principal Versus Secondary Procedures
71(1)
Coding Qualified Diagnoses
72(1)
ICD-9-CM Coding System
72(3)
Disease Index Organization
75(2)
Basic Steps for Using the Index
77(1)
Organization of the Tabular List
78(4)
Basic Steps for Using the Tabular List
82(1)
Index Conventions
83(4)
Tabular List Conventions
87(5)
Working with Index Tables
92(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


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