Guide to Health Claims Examining

This comprehensive text presents the principles and theories behind health claims examining. It builds a complete understanding of all the skills necessary to process, pay, and apply claims as an examiner accurately and consistently. Highlights include: Learning objectives that identify key skills and concepts, "On the Job Now"-Professional self-assessment sections, "Practice Pitfalls"-Bad habits to avoid in the workplace, Chapter review questions and in-text exercises. This book should be used in conjunction with the workbook, The Practice of Health Claims Examining, Second Edition, which simulates daily duties as if the student were working for an insurance carrier. Book jacket.

Introduction to Health Claims Examining	p. 1
Introduction to Technical and Legal Issues	p. 3
The Rising Cost of Healthcare	p. 4
Types of Insurance	p. 6
Employee Benefits	p. 7
Types of Health Benefit Plans	p. 8
Departments in an Insurance Company	p. 9
Claims Examiner's Responsibilities	p. 11
The Department of Insurance	p. 13
Legal Issues Pertaining to Disclaimers	p. 14
Legal Issues Pertaining to Privacy Guidelines	p. 16
Legal Issues Pertaining to Fraud	p. 19
HIPAA and Fraud and Abuse	p. 23
Investigation	p. 24
Embezzlement	p. 26
Legal Damages	p. 26
Maintenance of Records	p. 28
Subpoenas	p. 28
Resource Manuals and Billing Forms	p. 34
ICD-9-CM	p. 35
"CPT/RVS"	p. 36
"CDT"	p. 37
HCPCS	p. 37
Physicians' Desk Reference	p. 37
Medical Dictionary	p. 38
Merck Manual	p. 38
"Red Book" and "Blue Book"	p. 38
CMS-1500 Form	p. 40
1500 Health Insurance Claim Form (Version 08/05)	p. 49
UB-92	p. 52
Uniform Bill (UB-04)	p. 56
Contract Interpretation and Administration	p. 81
Medical Plan Provisions	p. 83
Contract Validity	p. 84
Group Contracts	p. 84
Contract Provisions	p. 85
Contract Benefits	p. 87
Eligibility	p. 91
Employee Eligibility	p. 91
Dependent Eligibility	p. 93
Employee Effective Date of Coverage	p. 94
Dependent Effective Date of Coverage	p. 96
Open Enrollment	p. 97
Termination of Coverage	p. 97
Continuation of Coverage	p. 97
General Plans and Provisions	p. 104
Acts of Third Parties	p. 105
Completion of the Right of Reimbursement Claims Ledger Sheet	p. 110
Subrogation	p. 110
Preexisting Conditions	p. 111
Mental Health Parity Act	p. 119
Mandates	p. 119
Medical Benefit Structures	p. 133
Benefit Definitions	p. 134
Benefit Calculations	p. 135
Calculating the Deductible	p. 135
Basic Benefits	p. 141
Common Basic Benefits	p. 142
Basic Major Medical Benefits	p. 145
Comprehensive Major Medical Benefits	p. 146
Computing Stoploss	p. 146
Usual, Customary, and Reasonable (UCR)	p. 148
Resource-Based Relative Value Study	p. 149
Calculating UCR	p. 149
Fee Schedules	p. 159
Cost Containment Programs	p. 160
Managed Care	p. 168
Medical Case Management	p. 163
Medical Claims Examining Guidelines and Procedures	p. 169
Medical Claims Administration	p. 171
Maintenance of Claim Files	p. 172
Claim File Documentation	p. 173
Claim Investigation	p. 174
Referrals	p. 174
Pended Claims	p. 176
Claim Processing	p. 176
Good Claim Practices	p. 178
Unbundling of Services	p. 179
Separate Procedures	p. 180
Payment Worksheet	p. 180
Processing the Claim	p. 184
Quick Reference Formulas	p. 191
Claim Office Administration	p. 191
Prescription Drug Claims	p. 194
Coordination of Benefits	p. 195
Definitions	p. 195
Order of Benefit Determination Rules	p. 197
Right to Receive and Release Information	p. 198
Right of Recovery	p. 198
Health Maintenance Organizations	p. 199
Preferred Provider Organizations	p. 199
Tricare	p. 199
Recognizing the Presence of Dual Coverage	p. 200
COB Worksheet	p. 201
Adjustments	p. 203
Physician's, Clinical, and Hospital Services Claims	p. 211
CPT Coding Evaluation & Management	p. 212
CPT Coding Medicine	p. 216
Maintenance Therapy	p. 222
Modifiers for Evaluation and Management and Medicine Codes	p. 223
X-ray and Laboratory Services	p. 225
Radiology (X-Ray)	p. 225
Modifiers for Radiology (X-Ray) Codes	p. 226
Pathology (Lab)	p. 226
Component Charges	p. 229
Modifiers for Pathology (Lab) Codes	p. 229
Hospital Services	p. 230
UB-92 Billing Form	p. 230
Ambulance Services	p. 237
Durable Medical Equipment (DME) Billing Procedures	p. 238
Types of Durable Medical Equipment (DME)	p. 241
Surgery and Anesthesia Claims	p. 262
Surgical Procedures	p. 263
Surgery and the CPT	p. 264
General Guidelines	p. 267
Maternity Expenses	p. 271
Cosmetic Surgery	p. 274
Obesity Surgery	p. 280
Cosurgeons	p. 281
Assistant Surgeons	p. 281
Podiatry	p. 281
Surgical Coding for Podiatry	p. 283
Conditions of the Foot and Treatment Procedures	p. 283
Surgery Modifiers	p. 288
Anesthesia	p. 289
Anesthesia CPT Coding	p. 290
Anesthesia Handling Procedures	p. 290
Calculating Anesthesia	p. 293
Modifiers	p. 293
Monitored Anesthesia Care	p. 294
Medical Direction of Anesthesiology	p. 295
Pain Control	p. 295
Miscellaneous	p. 296
Medicare and Medicaid	p. 313
TEFRA/DEFRA	p. 314
Medicare Eligibility	p. 315
Providers of Service	p. 315
The Parts of Medicare	p. 315
Approved or Reasonable Charges	p. 318
Medicare Assignment of Benefits	p. 318
Coordination of Benefits with Medicare	p. 319
Estimating Medicare Coverage	p. 326
Diagnosis-Related Group Billing	p. 326
Medicaid	p. 327
Health Insurance Payment Demand	p. 327
HIPD Handling Procedures	p. 330
Workers' Compensation	p. 336
Employee Activities	p. 337
Use of Company Vehicles	p. 338
Business Trips	p. 338
Company Parking Lot	p. 338
Occupational Disease	p. 338
Types of Claims	p. 338
Nondisability Claims	p. 338
Temporary Disability Claims	p. 339
Permanent Disability Claims	p. 339
Death Benefits	p. 339
Rehabilitation Benefits	p. 339
Doctor's Reports Needed to Process a Claim	p. 339
Doctor's First Report	p. 340
Progress Reports	p. 342
Physician's Final Report	p. 342
Delay of Adjudication	p. 342
Fraud and Abuse	p. 343
Liens	p. 344
Reversals	p. 347
Managed Care Claims	p. 352
HMO Coverage	p. 355
Groups/Independent Physician Associations	p. 356
Capitation Payments	p. 358
Billing for Services	p. 359
Authorizations, Referrals, and Second Opinions	p. 360
Miscellaneous Services	p. 362
Claim Payments	p. 363
Processing the Claim	p. 366
Denial of a Claim or Service	p. 366
Appeals	p. 367
Reinsurance/Stoploss	p. 367
Dental Claims Examining Guidelines and Procedures	p. 377
Dental Terminology, Anatomy, and Physiology of the Mouth	p. 379
Common Dental Terms and Procedures	p. 380
The Oral Cavity	p. 404
The Jaw	p. 406
Diseases of the Mouth	p. 406
The Teeth	p. 407
Growth and Development of Teeth	p. 413
Diseases of the Teeth	p. 413
Dental Plan Provisions and Benefit Structures	p. 424
Calculating Dental UCR	p. 425
Types of Dental Plans	p. 425
Understanding Dental Contracts	p. 426
General Guidelines	p. 427
Cost Containment	p. 431
Major Medical Coverage for Dental Procedures	p. 434
Temporary Restorations	p. 436
X-Rays	p. 436
Anesthesia	p. 438
Sedative Fillings	p. 438
Cosmetic Services	p. 438
Unspecified and By Report Procedures	p. 439
Dental Services and Coding	p. 441
Dental Professionals	p. 442
Dental Treatment	p. 442
Dental Coding	p. 443
Diagnostic Services	p. 443
Preventive Services	p. 445
Restorative Services	p. 446
Endodontics	p. 450
Periodontic Services	p. 452
Prosthodontic Services (Removable)	p. 454
Maxillofacial Prosthetics	p. 456
Implant Services	p. 457
Prosthodontic Services (Fixed)	p. 458
Oral and Maxillofacial Surgery	p. 459
Orthodontic Services	p. 461
Adjunctive General Services	p. 462
Coverage for TMJ	p. 463
Dental Claims Administration	p. 472
The ADA Dental Claim Form	p. 473
Patient Claim Form	p. 477
Predetermination and Preauthorization	p. 477
Claim Analysis	p. 477
Eligibility	p. 477
Other Insurance	p. 480
Provider Authority	p. 480
Coverage of Services	p. 480
Evaluating the Services	p. 481
Processing the Claim	p. 481
Completing the Claim Payment Worksheet	p. 482
Dental Form Letters	p. 489
Handling Fraudulent Dental Claims	p. 490
General Office Procedures	p. 501
Basic Office Functions and Effective Communication	p. 503
Verbal Communication	p. 504
Telephone Communication	p. 504
Telephone Techniques	p. 504
Phone Calls	p. 505
Telephone Etiquette	p. 506
Written Communication	p. 509
Letter Writing	p. 510
Parts of a Business Letter	p. 511
Terminology	p. 512
Content Structure	p. 513
Correspondence Containing Negative Content	p. 514
Proofreading	p. 514
Format of the Letter	p. 514
Memos	p. 519
Specialized Letter Writing	p. 521
Denial Letters	p. 521
Conclusions and Alternatives	p. 522
Notice of Availability	p. 522
Right of Review/ERISA	p. 522
Adjustments	p. 523
Mail	p. 523
Office Machines	p. 528
Tickler Files	p. 529
Postal Abbreviations	p. 529
Securing Employment	p. 537
Job Search Preparation	p. 539
Calculator Basics	p. 540
Key Descriptions	p. 540
Printer Tape Symbols	p. 541
Computer Basics	p. 542
The Computer	p. 543
The Monitor	p. 543
The Keyboard	p. 543
Computer Terms	p. 547
Job Search Basics	p. 549
Job Search Objectives	p. 549
Uniqueness	p. 549
Target Audience	p. 549
Build Your Database	p. 550
The Resume	p. 550
The Cover Letter	p. 553
Marketing Yourself	p. 554
The Job Interview	p. 554
Getting Paid What You Are Worth	p. 557
Appendices	p. 573
Contracts	p. 575
Conversion Factors and Relative Value Studies	p. 590
Tables	p. 603
Forms	p. 620
Glossary	p. 629
Credits	p. 644
Index	p. 645
Table of Contents provided by Ingram. All Rights Reserved.

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Health claims examining and medical billing are two of the fastest-growing employment opportunities in the United States today. Insurance companies, medical offices, hospitals and other health care providers are in great need of trained personnel to create and process claims. With the aid of this textbook, you can learn the skills necessary to become a successful health claims examiner. The material has been designed to be comprehensive, yet user-friendly. The text follows a logical learning format by beginning with a broad base of information and then, step by step, following the course of a health claim from billing to examining. This text may be used with ICDC Publishing's Guide to Medical Billingand the Medical Biller/Health Claims Examiner Curriculum Program. The curriculum is developed in easy-to-understand, standalone modules. Special Features The following special features of the text enhance understanding and retention of the material covered: Each chapter begins with learning objectivesto focus the student on the most important topics covered in that chapter. Key words and conceptsintroduce the student to new terminology and processes. The straightforward, easy-to-understand writing stylepresents information clearly and concisely. Questions for Reviewat the end of each chapter are designed to reinforce key concepts. Answering questions without looking back into the chapter will help readers determine if they have grasped the main principles within the chapter or if there is a need for further review. The Questions for Review also serve to prepare students for exams. Exercisesprovided with most chapters give students the opportunity to put their knowledge into practice. These hands-on, real-life exercises will ensure competence in claims examining. Honors Certificationchallenges encourage students to learn the material in order to graduate from a course "with honors." Answers for all Questions for Review and Exercises are contained in the instructor materials for the course, along with the Honors Certification tests and answers. This material is available to training facilities. The most important ingredient to success in this course is the desire to learn, without which the learning process is ineffective. The desire to learn can lead you to a rewarding career in the medical billing or health claims examining fields.