In this unit, you were introduced to the most common third-party insurance payers, including government payers such as Medicare, Medicaid, and TRICARE. Additionally, you reviewed the process for accurate claim processing and the various stages for claim status. This included the importance of adhering to Health Insurance Portability and Accountability Act (HIPAA) standards and code set transactions during the electronic claim submission process.

Use the Chapter 18 readings and a source from the CSU Online Library to respond to the prompts below.

· Identify the main reasons why insurance companies deny patient insurance claims.

· When filing insurance claims, how do HIPAA transaction code set standards apply? 

· What remedies might the patient and provider have regarding reversal of an insurance company’s decision to pay a patient’s claim?

· Describe the major differences between traditional Medicare and Medicare Advantage. Which appears to provide the best options for patients, and why?

· Summarize the average timely filing claim limits for common third-party payers as well as for Medicare, Medicaid, and TRICARE.

Your response must be at least two pages in length, not counting the title page or references page. You are required to use at least two sources in your response. One must be found from the CSU Online Library, and the other can be your textbook. Adhere to APA Style when constructing this assignment, including a title and reference page, and in-text citations and references for all sources that are used.

Resources

HTH 2305, Health Information Documentation Management 1 Course Learning Outcomes for Unit VII Upon completion of this unit, students should be able to: 1. Interpret health insurance coverage, including medical billing. 1.1 Summarize common third-party payers by describing types of insurance. 1.2 Describe all four parts of Medicare, including Medicaid. 1.3 Illustrate the three main types of TRICARE coverage available. 2. Apply legal and ethical standards needed to accurately manage insurance claims. 2.1 Recognize key insurance claim submission statuses. 4. Summarize patient confidentiality, including Health Insurance Portability and Accountability Act (HIPAA) guidelines in health care. 4.1 Recognize the importance of adhering to HIPAA standards when submitting protected health information electronically for payment. 4.2 Describe issues related to protected health information (PHI) and insurance claim denials. Course/Unit Learning Outcomes Learning Activity 1.1 Unit Lesson Chapter 18, pp. 558–599 Unit VII Homework 1 Unit VII Homework 2 Unit VII Case Study 1.2 Unit Lesson Chapter 18, pp. 558–599 Unit VII Homework 1 Unit VII Case Study 1.3 Unit Lesson Chapter 18, pp. 558–599 Unit VII Homework 1 2.1 Unit Lesson Chapter 18, pp. 558–599 Unit VII Homework 1 Unit VII Homework 2 Unit VII Case Study 4.1 Unit Lesson Chapter 18, pp. 558–599 Unit VII Homework 1 Unit VII Homework 2 Unit VII Case Study 4.2 Unit Lesson Chapter 18, pp. 558–599 Unit VII Homework 1 Unit VII Case Study Reading Assignment Chapter 18: Health Insurance Systems and Claim Submission, pp. 558–599 UNIT VII STUDY GUIDE Timely Claims Submission Practices HTH 2305, Health Information Documentation Management 2 UNIT x

STUDY GUIDE Title Unit Lesson Introduction to Insurance Today, the majority of reimbursement from insurance companies is obtained by physician offices through payer contracts. Therefore, it is essential that administrative health care professionals are familiar with understanding common types of health insurance products (French, 2018). The insurance claim is a form used to request and process insurance payments via a contract. Processing claims accurately helps to ensure timely and correct payment for the provider or facility. This unit will focus on important concepts such as insurance terminology, types of insurance plans and programs, patient eligibility, coinsurance, deductibles, copayments, and filing claims (French, 2018). Third-party payers are private insurance companies and programs that pay claims for patients seen under government programs such as Medicare, Medicaid, and TRICARE. Third-party payers may also be private insurance companies that pay personal liability and worker’s compensation claims (French, 2018). Types of Insurance Individuals may purchase health insurance through a private commercial carrier and pay premiums or insurance may be purchased where many individuals are covered, which is called a group contract. An individual may be part of a Health Maintenance Organization (HMO) or could be a beneficiary under a federalor state-funded program such as Medicare, Medicaid, or TRICARE (French, 2018). Commercial insurance plans are both owned and administered by private companies. Private insurance plans may consist of traditional indemnity plans, group plans, or managed care plans. Some popular examples of commercial plans are Blue Cross/Blue Shield, Aetna, Allstate, and Farmers Insurance (French, 2018). Indemnity insurance, according to the textbook, is also considered a fee-for-service plan, which provides coverage for hospital or outpatient services if an individual becomes ill (French, 2018). Indemnity plans offer flexibility for covered members in selecting the provider or healthcare facility of choice. This type of plan usually includes a deductible, which is the set amount the insured member is required to pay during a calendar or fiscal year before the benefits of the policy will begin. These amounts vary and could be $250, $500, or even thousands of dollars (French, 2018). Group insurance is obtained through an employer. Individuals pay a premium for health benefits. If an individual separates from their employer, they may be eligible to continue their benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA; French, 2018). COBRA applies to employees who have left their employment and require an extension of insurance benefits for themselves and/or family members for a limited period of time. COBRA premium rates are higher than previous rates paid by the employer for the same insurance. Managed care plans operate under several different contracts with physicians and healthcare facilities. Managed care plans require the collection of copayments prior to services being rendered and use provider networks and facilities when treating patients under a managed care model (French, 2018). Insurance Plans and Programs Medicaid is a plan that is sponsored by state, federal, and local government. It is considered an assistance program versus an insurance plan. Each state administers and operates its own Medicaid program, and coverage and benefits can also vary by state. Some states have now adopted managed care systems as an effort to control costs. While Medicaid eligibility requirements can vary by state, this program was designed to assist low-income individuals, the elderly, pregnant women, and members of families who are receiving aid for dependent children (French, 2018). HTH 2305, Health Information Documentation Management 3 UNIT x STUDY GUIDE Title Medicare is administered by the Centers for Medicare and Medicaid Services (CMS) and is a federally funded program. A person is eligible for Medicare coverage beginning at age 65. Individuals who are disabled, which includes disabled children; adults who are diagnosed with amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease); chronic kidney disease, which requires dialysis; or end-stage renal disease (ESRD) that requires a transplant, are all eligible for Medicare benefits (French, 2018). There are four parts to Medicare coverage. Eligible Medicare beneficiaries cannot be on both traditional Medicare (Part A, B, and D coverage) as well as Part C (French, 2018). Individuals must choose the option that best meets their needs. Therefore, it is very important for administrative healthcare professionals to inquire as to what type of Medicare coverage an individual has. TRICARE TRICARE is available to eligible active-duty military service members and their dependents. An active-duty service member on TRICARE is referred to as a sponsor. All sponsors and their eligible dependents need to be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS), which is a computerized database. There are three types of TRICARE programs: Standard, Extra, and Prime. TRICARE Standard is the basic plan wherein the patient pays a deductible and copayment for outpatient care and cost-sharing percentages (French, 2018). Patients need to seek treatment from in-network providers and facilities for maximum benefits. TRICARE Extra is a preferred provider organization (PPO). Beneficiaries do not have to enroll or pay an annual fee. Deductibles and copayment amounts are lower than they are in the Standard plan, and members can seek treatment in and out of network and receive benefits from both TRICARE Standard options (French, 2018). TRICARE Prime • Covers hospital costs, skilled nursing and home care, and hospice care Medicare Part A • Covering outpatient medical services and considered a supplement to Part A hospital coverage, Part B covers outpatient visits, diagnostic testing, laboratory, and other ambulatory services (French, 2018). Medicare Part B • Offering more healthcare options by acting as a managed care model, this provides inpatient, outpatient, and prescription drug coverage to eligible beneficiaries. It is also called Medicare Senior Advantage. Medicare Part C •Is voluntary prescription drug coverage where a Medicare beneficiary may elect and pay a premium Medicare Part D The four parts of Medicare coverage TRICARE Standard TRICARE Extra TRICARE Prime Three types of TRICARE programs HTH 2305, Health Information Documentation Management 4 UNIT x STUDY GUIDE Title is a managed care (Health Maintenance Organization type) program that offers the most affordable and comprehensive coverage options for sponsors and dependents. There are no annual deductibles, and copayments may vary (French, 2018). Verification of Insurance Coverage Regardless of which type of insurance plan an individual may have, verifying coverage is a critical component that needs to be completed prior to every patient visit by administrative healthcare professionals. A copy of the patient’s insurance card needs to be obtained to verify if the physician practice or facility participates in the patient’s plan. All demographic information for the patient needs to be on file, including insurance eligibility and benefit information (French, 2018). When contacting the insurance company via phone or electronically, verify the patient’s name, date of birth, basic benefits, and any exclusions or non-covered services. Additionally, determine the patient’s financial responsibility for a deductible, copayment, or any other out-ofpocket expenses. All documentation should be entered into the patient’s electronic or paper medical record. Finally, the patient should be notified of eligible or non-eligible insurance benefits and any specific restrictions that may apply prior to services being rendered (French, 2018). Failure to obtain proper insurance coverage verification can result in having incorrect or outdated information on file, which can cause delays or even payment denials (French, 2018). Health Insurance Claim When all data has been collected, the insurance claim will go through four major stages, which include: The CMS-1500 claim form is accepted by most insurance carriers for outpatient services. The preferred method of submission is electronic; however, there may be some qualifying circumstances where a paper claim may be filed to an insurance carrier. All blocks of the CMS-1500 claim form need to be completed according to optical character recognition (OCR) and HIPAA Transaction Code Set standards (French, 2018). This Transaction Code Set is required to ensure that a patient’s electronic protected health information is secure during the transmission process. All covered entities such as providers, clearinghouses, vendors, and health insurance carriers are required to adhere to HIPAA standards in this area. Claim submission Claim processing Claim adjudication Payment The four stages that an insurance claim goes through HTH 2305, Health Information Documentation Management 5 UNIT x STUDY GUIDE Title Claim status can be described in several ways. A clean claim means that the claim submitted contains all necessary elements to be processed and paid correctly. A dirty claim means that the claim was submitted with errors. An incomplete claim is missing required information and needs to be resubmitted to the insurance carrier. A denied claim has been rejected due to a technical error or a payment policy such as a non-covered benefit. Pending claims are held in suspense and need to be reviewed further, resulting in either a payment or denial. Rejected claims have been submitted to the insurance payer but have technical errors, require correction, or require reprocessing. Suspended claims are held by the insurance company and are considered pending due to an error or a request for additional information (French, 2018). Claim adjudication is the decision-making process by the insurance company that will ultimately result in payment or denial of the claim. If the claim meets all requirement parameters, it will be approved for payment by the insurance carrier and sent to the physician or healthcare facility (French, 2018). Conclusion Understanding the major types of insurance, including insurance plans and programs, is essential for administrative healthcare professionals. These include Medicare, Medicaid, TRICARE, and private insurance carriers. Regardless of what type of insurance carrier or plan a patient has, always verify patient coverage prior to their visit to ensure you have captured accurate information when preparing an insurance claim for submission. Be cognizant of the various claim statuses that insurance companies use when claims are received, and make it a goal to send clean claims every time to reduce the chance of denials. Reference French, L. L. (2018). Administrative medical assisting (8th ed.). Cengage Learning. Clean Claim Dirty Claim Incomplete Claim Denied Claim Pending Claim Rejected Claim Suspended Claim Several ways of describing insurance claim status