Health Insurance Fundamentals

Health Insurance Coverage

• Types of health insurance coverage include:
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Medicare
  • Others

Insurance Authorization

• Procedures for obtaining insurance authorization for patient treatment or testing:
  • Obtaining prior authorization from insurance company
  • Providing necessary documentation and medical information
  • Meeting specific requirements and criteria

Insurance Forms and Statements

• Commonly used insurance forms and statements:
  • Claim forms (e.g., CMS-1500, UB-04)
  • Insurance cards
  • Benefits statements
  • Explanation of Benefits (EOB) forms

ICD-11 Codes

• International Classification of Diseases (ICD-11) codes used for billing purposes and insurance claims:
  • Diagnoses codes (e.g., I25.110 for acute myocardial infarction)
  • Procedure codes (e.g., 0W9930Z for insertion of pacemaker)
  • others

Referral Procedures

• Procedures for processing referrals:
  • Obtaining necessary referrals from primary care physicians
  • Coordinating with specialists and providers
  • Ensuring timely and accurate processing

Billing Statement

• Preparing a billing statement:
  • Accurately documenting services and charges
  • Including necessary codes and modifiers
  • Ensuring compliance with insurance regulations

Explanation of Benefits (EOB)

• Interpreting an Explanation of Benefits (EOB) form:
  • Understanding coverage and payment information
  • Identifying patient responsibility and out-of-pocket costs
  • Reviewing claims status and adjudication

Submitting Insurance Claims

• Procedures for submitting insurance claims:
  • Electronically submitting claims through clearinghouses or portals
  • Ensuring accuracy and completeness of claims
  • Following up on claims status and resolving issues

Health Insurance Coverage

• Types of health insurance coverage include:
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Medicare
  • Others

Insurance Authorization

• Procedures for obtaining insurance authorization for patient treatment or testing:
  • Obtaining prior authorization from insurance company
  • Providing necessary documentation and medical information
  • Meeting specific requirements and criteria

Insurance Forms and Statements

• Commonly used insurance forms and statements:
  • Claim forms (e.g., CMS-1500, UB-04)
  • Insurance cards
  • Benefits statements
  • Explanation of Benefits (EOB) forms

ICD-11 Codes

• International Classification of Diseases (ICD-11) codes used for billing purposes and insurance claims:
  • Diagnoses codes (e.g., I25.110 for acute myocardial infarction)
  • Procedure codes (e.g., 0W9930Z for insertion of pacemaker)
  • others

Referral Procedures

• Procedures for processing referrals:
  • Obtaining necessary referrals from primary care physicians
  • Coordinating with specialists and providers
  • Ensuring timely and accurate processing

Billing Statement

• Preparing a billing statement:
  • Accurately documenting services and charges
  • Including necessary codes and modifiers
  • Ensuring compliance with insurance regulations

Explanation of Benefits (EOB)

• Interpreting an Explanation of Benefits (EOB) form:
  • Understanding coverage and payment information
  • Identifying patient responsibility and out-of-pocket costs
  • Reviewing claims status and adjudication

Submitting Insurance Claims

• Procedures for submitting insurance claims:
  • Electronically submitting claims through clearinghouses or portals
  • Ensuring accuracy and completeness of claims
  • Following up on claims status and resolving issues

Health Insurance Coverage

• Types of health insurance coverage include:
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Medicare
  • Others

Insurance Authorization

• Procedures for obtaining insurance authorization for patient treatment or testing:
  • Obtaining prior authorization from insurance company
  • Providing necessary documentation and medical information
  • Meeting specific requirements and criteria

Insurance Forms and Statements

• Commonly used insurance forms and statements:
  • Claim forms (e.g., CMS-1500, UB-04)
  • Insurance cards
  • Benefits statements
  • Explanation of Benefits (EOB) forms

ICD-11 Codes

• International Classification of Diseases (ICD-11) codes used for billing purposes and insurance claims:
  • Diagnoses codes (e.g., I25.110 for acute myocardial infarction)
  • Procedure codes (e.g., 0W9930Z for insertion of pacemaker)
  • others

Referral Procedures

• Procedures for processing referrals:
  • Obtaining necessary referrals from primary care physicians
  • Coordinating with specialists and providers
  • Ensuring timely and accurate processing

Billing Statement

• Preparing a billing statement:
  • Accurately documenting services and charges
  • Including necessary codes and modifiers
  • Ensuring compliance with insurance regulations

Explanation of Benefits (EOB)

• Interpreting an Explanation of Benefits (EOB) form:
  • Understanding coverage and payment information
  • Identifying patient responsibility and out-of-pocket costs
  • Reviewing claims status and adjudication

Submitting Insurance Claims

• Procedures for submitting insurance claims:
  • Electronically submitting claims through clearinghouses or portals
  • Ensuring accuracy and completeness of claims
  • Following up on claims status and resolving issues

Test your knowledge of health insurance basics, including types of coverage, insurance forms, and billing procedures. Learn about ICD-11 codes and how to process referrals and interpret explanations of benefits.