Descripciones mejoradas de Syndetics:

Understanding 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. Also available are Web Tutor and Blackboard versions.

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• Preface(p. xi)
• Chapter 1 Health Insurance Specialist--Roles and Responsibilities(p. 1)
• Employment Opportunities(p. 1)
• Basic Skill Requirements(p. 3)
• Health Insurance Specialist Responsibilities(p. 6)
• Professional Certification(p. 7)
• Review(p. 8)
• Chapter 2 Legal Considerations(p. 9)
• Breach of Confidentiality(p. 10)
• Claims Information Telephone Queries(p. 13)
• Facsimile Transmission(p. 15)
• Confidentiality and the Internet(p. 16)
• Insurance Fraud and Abuse(p. 16)
• Review(p. 18)
• Chapter 3 Introduction to Health Insurance(p. 21)
• What Is Health Insurance?(p. 21)
• Disability and Liability Insurance(p. 22)
• Major Developments in Health Insurance(p. 23)
• Current Mixture of Health Insurance Plans(p. 28)
• Third-Party Reimbursement Methods(p. 29)
• Review(p. 30)
• Chapter 4 Managed Health Care(p. 31)
• What Is Managed Health Care?(p. 31)
• Six Managed Care Models(p. 32)
• HMO Accreditation(p. 35)
• Government Managed Care Ventures(p. 36)
• Effects of Managed Care on Administrative Procedures(p. 36)
• Review(p. 37)
• Chapter 5 Life Cycle of an Insurance Claim(p. 39)
• Development of the Claim(p. 40)
• New Patient Interview and Check-in Procedure(p. 40)
• Established Patient Return Visit(p. 49)
• Post Clinical Check-Out Procedures(p. 53)
• Computerized Practice Procedure Modifications(p. 58)
• Insurance Company Processing of a Claim(p. 60)
• Maintaining Provider Insurance Claim Files(p. 62)
• Review(p. 64)
• Chapter 6 Diagnosis Coding(p. 67)
• ICD-9-CM(p. 68)
• Primary Versus Principal Diagnosis(p. 69)
• Principal Versus Secondary Procedures(p. 71)
• Coding Qualified Diagnoses(p. 72)
• ICD-9-CM Coding System(p. 72)
• Disease Index Organization(p. 75)
• Basic Steps for Using the Index(p. 77)
• Organization of the Tabular List(p. 78)
• Basic Steps for Using the Tabular List(p. 82)
• Index Conventions(p. 83)
• Tabular List Conventions(p. 87)
• Working with Index Tables(p. 92)
• Coding Special Disorders(p. 102)
• HCFA ICD-9-CM Guidelines(p. 106)
• Office Procedure Errors Contributing to Inaccurate Diagnosis Coding(p. 107)
• Review(p. 108)
• Chapter 7 CPT Procedure Coding(p. 111)
• CPT Coding System(p. 112)
• CPT Format(p. 113)
• CPT Symbols and Conventions(p. 115)
• CPT Index(p. 121)
• Basic Steps for Coding Procedures(p. 123)
• Surgery Overview(p. 124)
• Notes for Coding Special Surgery Cases(p. 129)
• Medicine Section Overview(p. 133)
• Radiology Section Overview(p. 135)
• Pathology/Laboratory Section Overview(p. 137)
• Evaluation and Management Services Overview(p. 139)
• CPT Modifiers(p. 151)
• Review(p. 162)
• Chapter 8 HCPCS Coding System(p. 165)
• HCPCS Procedure Code Organization(p. 165)
• HCPCS National (Level II) Codes(p. 166)
• The National HCPCS Index(p. 168)
• Determining Carrier Responsibility(p. 171)
• Using Level II National HCPCS Codes(p. 172)
• HCPCS Modifiers(p. 174)
• Using HCPCS Level II MOdifiers(p. 174)
• Review(p. 176)
• Chapter 9 HCFA Reimbursement Issues(p. 179)
• The Medicare Fee Schedule(p. 180)
• HCFA Regulations(p. 182)
• Medicare Reimbursement Issues(p. 184)
• Correct Coding Initiative(p. 189)
• Medicare Compliance Plans(p. 193)
• Review(p. 194)
• Chapter 10 Coding From Source Documents(p. 195)
• Applying ICD-9-CM Coding Guidelines(p. 195)
• CPT/HCPCS Billing Considerations(p. 199)
• Coding Clinical Scenarios(p. 200)
• Coding Medical Reports(p. 204)
• Coding Operative Reports(p. 210)
• Chapter 11 Essential Claim Form Instructions(p. 221)
• General Billing Guidelines(p. 222)
• Optical Scanning Guidelines(p. 224)
• Reporting Diagnoses: ICD-9-CM Codes(p. 227)
• Instructions for Line 24(p. 228)
• Federal Tax ID Number(p. 232)
• Reporting the Billing Entity(p. 233)
• Processing Secondary Claims(p. 234)
• Common Errors that Delay Processing(p. 235)
• Final Processing Steps of Paper Claims(p. 236)
• Maintaining Insurance Claim Files for the Practice(p. 236)
• Review(p. 237)
• Chapter 12 Filing Commercial Claims(p. 239)
• Insurance Program Comparison Chart(p. 240)
• Step-by-Step Instructions for Primary Commercial Claims(p. 240)
• Patient and Policy Identification(p. 241)
• Diagnostic and Treatment Data(p. 247)
• Instructions for Line 24(p. 251)
• Provider/Billing Entity Identification(p. 253)
• Commercial Secondary Claims(p. 256)
• Guidelines for Primary and Supplemental Policy(p. 259)
• Same Carrier(p. 259)
• Different Carriers(p. 259)
• Chapter 13 Blue Cross and Blue Shield Plans(p. 261)
• Brief History(p. 262)
• BCBS Association(p. 263)
• BCBS Distinctive Features(p. 264)
• Participating Providers(p. 264)
• Nonparticipating Providers(p. 265)
• Traditional Fee-for-Service Coverage(p. 265)
• Nationwide Accounts(p. 266)
• Bluecard Program(p. 267)
• BCBS and Managed Care(p. 268)
• BCBS Health Maintenance Organization Plan(p. 271)
• Medicare Supplemental Plans(p. 271)
• Billing Information Summary(p. 271)
• Step-by-Step Instructions--Primary BCBS Claims(p. 272)
• Two BCBS Full Benefit Policies(p. 284)
• BCBS Secondary Claims(p. 287)
• Review(p. 292)
• Chapter 14 Medicare(p. 293)
• Medicare Eligibility(p. 294)
• Medicare Enrollment(p. 295)
• Part A Coverage(p. 296)
• Part B Coverage(p. 298)
• Participating Providers(p. 300)
• Nonparticipating Provider Restrictions(p. 300)
• Medicare Fee Schedule (MFS)(p. 303)
• Medicare as a Secondary Payor(p. 304)
• Medicare Supplemental Plans(p. 308)
• Medicare and Managed Care(p. 311)
• Medicare--HMO Program(p. 311)
• HMO Primary Plans(p. 313)
• Medicare+Choice(p. 313)
• Billing Information Notes(p. 314)
• Step-by-Step Claim Form Instructions(p. 315)
• Primary Medicare with a Medigap Policy(p. 330)
• Medicare and NonHMO Medicaid (Medical) Claims(p. 332)
• When Medicare Is the Secondary Claims Payer(p. 334)
• Review(p. 339)
• Chapter 15 Medicaid(p. 341)
• Federal Eligibility Requirements(p. 344)
• Federal Benefits(p. 345)
• State Services(p. 346)
• Medicaid as a Secondary Payer(p. 347)
• Participating Providers(p. 348)
• Medicaid and Managed Care(p. 348)
• Billing Information Notes(p. 348)
• Step-by-Step Claim Form Instructions(p. 351)
• Secondary Medicaid Claims(p. 361)
• Review(p. 363)
• Chapter 16 Tricare/Champus(p. 365)
• TRICARE Overview(p. 366)
• TRICARE Eligibility(p. 370)
• TRICARE Preauthorization(p. 371)
• Covered Services(p. 373)
• TRICARE as a Secondary Payor(p. 375)
• TRICARE Limiting Charges(p. 376)
• Uniformed Services Retiree HMO Plan(p. 376)
• TRICARE Supplemental Plans(p. 376)
• TRICARE Billing Information(p. 377)
• TRICARE Primary Claim Instructions(p. 379)
• TRICARE as Secondary Payor Instructions(p. 389)
• Review(p. 392)
• Chapter 17 Workers' Compensation(p. 395)
• Federal Compensation Programs(p. 396)
• State-Sponsored Coverage(p. 396)
• Eligibility(p. 397)
• Classification of On-the-Job Injuries(p. 397)
• OSHA Act of 1970(p. 399)
• Special Handling of Workers' Compensation Cases(p. 399)
• Workers' Compensation and Managed Care(p. 400)
• First Report of Injury(p. 400)
• Progress Reports(p. 403)
• Billing Information Notes(p. 403)
• Workers' Compensation Claim Instructions--Patient and Policy Identification(p. 406)
• Diagnostic and Treatment Data(p. 410)
• Provider/Billing Entity Identification(p. 415)
• Review(p. 419)
• Appendix I Case Study Set One(p. 421)
• Appendix II Clinic Billing Manual and Case Studies(p. 437)
• Appendix III Forms(p. 475)
• Appendix IV Answers to Coding Exercises(p. 481)
• Appendix V Bibliography(p. 491)
• Glossary(p. 495)
• Index(p. 523)