Table of contents for Health insurance today : a practical approach / Janet I. Beik.

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Contents
UNIT 1	BUILDING A FOUNDATION
Chapter 1	MEDICAL INSURANCE: WHERE DID IT COME FROM?
What Is Insurance?, 4
History, 5
Metamorphosis of Medical Insurance, 6
Key Health Insurance Issues, 9
	How Do People Get Health Insurance?, 10
	Access to Health Insurance, 10
 Why Do Healthcare and Medical Insurance Cost So Much?, 11
 Cost Sharing, 12
Reasons for Health Insurance, 12
Medical Insurance Plans, 13
Chapter 2	TOOLS OF THE TRADE: A CAREER AS A HEALTH (MEDICAL) 
INSURANCE PROFESSIONAL
Your Future as a Health Insurance Professional {COMP: Pls. add commas and page numbers 
for Ch. 2+ entries}
	Required Skills and Interests
Job Duties and Responsibilities
Career Prospects
	Opportunities
	Rewards
Certification Possibilities
Chapter 3	THE LEGAL AND ETHICAL SIDE OF MEDICAL INSURANCE
Medical Law and Liability
	Employer Liability
	Employee Liability
Insurance and Contract Law
	Elements of a Legal Contract
	Termination of Contracts
Medical Law and Ethics Applicable to Health Insurance
Important Legislation Affecting Health Insurance
	Federal Privacy Act of 1974
	Federal Omnibus Budget Reconciliation Act of 1980
	Tax Equity and Fiscal Responsibility Act of 1982
	Consolidated Omnibus Budget Reconciliation Act of 1986
	Federal False Claim Amendments Act of 1986
	Fraud and Abuse Act
	Federal Omnibus Budget Reconciliation Act of 1987
Medical Ethics and Medical Etiquette
	Medical Ethics
	Medical Etiquette
Documentation of Patient Medical Record
Health Insurance Portability and Accountability Act and Compliance
	Impact of Health Insurance Portability and Accountability Act
	Enforcement of Confidentiality Regulations of Health Insurance Portability and 
Accountability Act
	Developing a Compliance Plan
The Medical Record
	Purposes of a Medical Record
	Complete Medical Record
	Who Owns Medical Records?
	Retention of Medical Records
	Access to Medical Records
	Releasing Medical Record Information
Confidentiality and Privacy
	Confidentiality
	Privacy
	Security
	Exceptions to Confidentiality
	Authorization to Release Information
	Exceptions for Signed Release of Information for Insurance Claims Submission
	Breach of Confidentiality
Healthcare Fraud and Abuse
	Defining Fraud and Abuse
	Preventing Fraud and Abuse
Chapter 4	TYPES AND SOURCES OF HEALTH INSURANCE
Types of Health Insurance
	Indemnity (Fee-for-Service)
	Managed Care
Sources of Health Insurance
	Group Contract
	Individual Policies
	Medicare
	Medicaid
	TRICARE/CHAMPVA
	Disability Insurance
	Medical Savings Account (MSA)
	Flexible Spending Account (FSA)
	Long-Term Care Insurance
	Consolidated Omnibus Budget Reconciliation Act
Other Terms Common to Third-Party Carriers
	Birthday Rule
	Coordination of Benefits
	Medical Necessity
	Usual, Reasonable, and Customary
	Participating versus Nonparticipating Providers
UNIT 2	HEALTH INSURANCE BASICS
Chapter 5	THE ¿UNIVERSAL¿ CLAIM FORM: CMS-1500
Universal Insurance Claim Form
	CMS-1500 Paper Form
	Who Uses the Paper CMS-1500 Form
Documents Needed when Completing the CMS-1500 Claim Form
	Patient Information Form
	Patient Insurance Identification Card
	Patient Health Record
	Encounter Form
	Patient Ledger Card
Completing the CMS-1500 Paper Form
	Patient/Insured Section
	Physician/Supplier Section
Preparing the Claim Form for Submission
	Proofreading
	Claim Attachments
	Tracking Claims
Generating Claims Electronically
Claims Clearinghouses
	Using a Clearinghouse
	Direct Claims
	Clearinghouses versus Direct
Chapter 6	TRADITIONAL FEE-FOR-SERVICE/PRIVATE PLANS
Traditional Fee-For-Service/Indemnity Insurance
How a Fee-for-Service Plan Works
Commercial or Private Health Insurance
	What Is Commercial Insurance? 
	Who Pays for Commercial Insurance?
	What Is Self-Insurance? 
Blue Cross and Blue Shield
	Overview
	History of Blue Cross
	History of Blue Shield
	Blue Cross and Blue Shield Programs
Participating versus Nonparticipating Providers
Completing the CMS-1500 Form for a Commercial Plan
Submitting Commercial Claims
	Timely Filing
	Filing Commercial Paper and Electronic Claims
Commercial Claims Involving Secondary Coverage
Chapter 7	UNRAVELING THE MYSTERIES OF MANAGED CARE
What Is Managed Care?
Common Types of Managed Care Organizations
	Preferred Provider Organization
	Health Maintenance Organization
Advantages and Disadvantages of Managed Care
	Advantages
	Disadvantages
Managed Care Certification and Regulation
	National Committee on Quality Assurance
	National Committee on Quality Assurance and Health Insurance Portability and 
 Accountability Act
	The Joint Commission
	Utilization Review
	Complaint Management
Preauthorization, Precertification, and Referrals
	Preauthorization
	Precertification
	Referrals
Health Insurance Portability and Accountability Act and Managed Care
Impact of Managed Care
	Impact of Managed Care on the Physician-Patient Relationship
	Impact of Managed Care on Healthcare Providers
Future of Managed Care
Chapter 8	UNDERSTANDING MEDICAID
What Is Medicaid?
Evolution of Medicaid
Structure of Medicaid
	Federal Government¿s Role
	States¿ Options
	Mandated Services
	Optional Services
	State Children¿s Health Insurance Program 
	Fiscal Intermediaries
Who Qualifies for Medicaid Coverage?
	Categorically Needy
	Medically Needy
	Early and Periodic Screening, Diagnosis, and Treatment Program
	Program for All-Inclusive Care for the Elderly
Payment for Medicaid Services
	Medically Necessary
	Prescription Drug Coverage
	Accepting Medicaid Patients
	Participating Providers
Verifying Medicaid Eligibility
	Medicaid Identification Card
	Automated Voice Response System
	Electronic Data Interchange
	Point-of-Sale Device
	Computer Software Program
	Benefits of the Eligibility Verification System
Medicare/Medicaid Relationship
	Special Medicare/Medicaid Programs
	Medicare and Medicaid Differences Explained
	Medicaid Managed Care
Medicaid Claim
	Completing the CMS-1500 Form Using Medicaid Guidelines
	Resubmission of Medicaid Claims
 Reciprocity
Medicaid and Third Party Liability
Common Medicaid Billing Errors
Medicaid Remittance Advice
Special Billing Notes
	Time Limit for Filing Medicaid Claims
	Copayments
	Accepting Assignment
	Services Requiring Prior Approval
	Preauthorization
	Retention, Storage, and Disposal of Records
Fraud and Abuse in the Medicaid System
	What Is Medicaid Fraud?
	Patient Abuse and Neglect
Chapter 9	CONQUERING MEDICARE¿S CHALLENGES
Medicare Program
	Medicare Program Structure
	Enrollment
	Premiums and Cost-Sharing Requirements
	Medicare Part C (Medicare Advantage Plans)
	Medicare Part D (Medicare Prescription Drug Benefit Plan)
	Program of All-Inclusive Care for the Elderly
Medicare Combination Coverages
	Medicare/Medicaid Dual Eligibility
	Medicare Supplement Policies
	Medicare and Managed Care
	Why This Information Is Important to the Health Insurance Professional
Preparing for the Medicare Patient
	Medicare¿s Lifetime Release of Information Form
	Determining Medical Necessity
	Local Medical Review Policies and Local Coverage Decisions
	Advanced Beneficiary Notice
	Health Insurance Claim Number and Identification Card
Medicare Billing
	Physician Fee Schedule
	Medicare Participating and Nonparticipating Providers
	Determining What Fee to Charge
Completing the CMS-1500 Form for Medicare Claims
	Completing a Medigap Claim
	Medicare Secondary Policy
	Medicare Part B Crossover Program
	Medicare/Medicaid Crossover Claims
	Deadline for Filing Medicare Claims
Medicare Summary Notice
	Information Contained on the Medicare Summary Notice
	Medicare Remittance Advice
	Electronic Funds Transfer
Medicare Audits and Appeals
	Audits
	Appeals
Quality Review Studies
	Quality Improvement Organizations
	Medicare Beneficiary Protection Program
	Peer Review Organizations
	Physician Review of Medical Records
	Healthcare Quality Improvement Program
	Payment Error Prevention Program
	Clinical Laboratory Improvement Amendment
Chapter 10	MILITARY CARRIERS: TRICARE AND CHAMPVA
Military Health Programs
TRICARE
	Who Is Eligible for TRICARE
	Who Is Not Eligible for TRICARE
	What TRICARE Pays
	TRICARE¿s Three Choices for Healthcare
	Other Health Insurance
	TRICARE Standard Supplemental Insurance
	TRICARE for Life
	Verifying Eligibility
	TRICARE Participating Providers
	TRICARE Claims Processing
	TRICARE Explanation of Benefits
CHAMPVA
	Eligibility
	CHAMPVA Benefits
	What CHAMPVA Pays
	CHAMPVA-TRICARE Connection
	CHAMPVA-Medicare Connection
	CHAMPVA and Health Maintenance Organization Coverage
	CHAMPVA Providers
	CHAMPVA for Life
	Filing CHAMPVA Claims
	CHAMPVA Claims Filing Deadlines
Instructions for Completing TRICARE/CHAMPVA Claim Forms
	Claims Filing Summary
	CHAMPVA Explanation of Benefits
	Claims Appeals and Reconsiderations
HIPAA and Military Insurers
Chapter 11	MISCELLANEOUS CARRIERS: WORKERS¿ COMPENSATION AND 
DISABILITY INSURANCE
Workers¿ Compensation
	History
	Federal Legislation and Workers¿ Compensation
	Eligibility
	Workers¿ Compensation Claims Process
	Special Billing Notes
	HIPAA and Workers¿ Compensation
	Workers¿ Compensation Fraud
Private and Employer-Sponsored Disability Income Insurance
	Defining Disability
	Disability Claims Process
Federal Disability Programs
	Americans with Disabilities Act
	Social Security Disability Insurance
	Supplemental Security Income
	State Disability Programs
	Centers for Disease Control and Prevention Disability and Health Team
	Ticket to Work Program
	Filing Supplemental Security Income/Social Security Disability Insurance Disability 
 Claims
UNIT 3	CRACKING THE CODES
Chapter 12	DIAGNOSTIC CODING
History and Development of Diagnostic Coding 
ICD-9-CM Manual 
	Volume 2, The Alphabetic List (Index) 
	Three Sections of Volume 2 
Process of Classifying Diseases
	Volume 1, The Tabular List
	Supplementary Sections of Volume 1
	Locating a Code in the Tabular List (Volume 1)
Conventions Used in ICD-9-CM
	Type Faces
	Instructional Notes
Essential Steps to Diagnostic Coding
Special Coding Situations
	Coding Signs and Symptoms
	Etiology and Manifestation Coding
	Symptoms, Signs, and Ill-Defined Conditions
	Combination Codes
	Coding Neoplasms
	Coding Hypertension
HIPAA and Coding
	Code Sets Adopted as HIPAA Standards
	HCPCS Level 3 Codes
ICD-10
	Three Volumes of ICD-10
	ICD-10-PCS
	Implementation of ICD-10
Chapter 13	PROCEDURAL, EVALUATION AND MANAGEMENT AND HCPCS 
CODING
Overview of Current Procedural Terminology Coding
	Purpose of CPT
	Development of CPT
Three Levels of Procedural Coding
CPT Manual Format
	Introduction and Main Sections
	Category III Codes
	Appendices A through L
	CPT Index
	Symbols Used in CPT
	Modifiers
	Unlisted Procedure or Service
	Special Reports
Format of CPT
	Importance of the Semicolon
	Section, Subsection, Subheading, and Category
	Cross-Referencing with See
Basic Steps of CPT Coding
Evaluation and Management (E & M) Coding
	Vocabulary Used in E & M Coding
	Documentation Requirements
	Three Factors to Consider
	Key Components
	Contributing Factors
	Prolonged Services
Subheadings of the Main E & M Section
	Outpatient or Other Outpatient Services
	Hospital Observation Status
	Hospital Inpatient Services
	Consultations
	Emergency Department Services
	Critical Care Services
	Neonatal Intensive Care Services
	Additional Categories of the E & M Section
E & M Modifiers
Importance of Documentation
	E & M Documentation Guidelines: 1995 versus 1997
	Deciding Which Guidelines to Use
Overview of the HCPCS Coding System
	HCPCS Level II Format
	Modifiers
HIPAA and HCPCS Coding
	Elimination of Unapproved Local Codes and Modifiers
	What Is a Crosswalk? 
Current Procedural Terminology, Fifth Edition (CPT-5)
UNIT 4	THE CLAIMS PROCESS
Chapter 14	THE PATIENT
Patient Expectations
	Professional Office Setting
	Relevant Paperwork and Questions
	Honoring Appointment Times
	Patient Load
	Getting Comfortable with the Healthcare Provider
	Privacy and Confidentiality
	Financial Issues
Future Trends
	Aging Population
	The Internet as a Healthcare Tool
	Patients as Consumers
HIPAA Requirements
	Authorization to Release Information
	HIPAA and Covered Entities
	HIPAA Requirements for Covered Entities
	Patient¿s Right of Access and Correction
	Accessing Information through Patient Authorization
	Accessing Information through De-Identification
Billing Policies and Practices
	Assignment of Benefits
	Keeping Patients Informed
	Accounting Methods
Billing and Collection
	Billing Cycle
	Arranging Credit or Payment Plans
	Problem Patients
Laws Affecting Credit and Collection
	Truth in Lending Act
	Fair Credit Billing Act
	Equal Credit Opportunity Act
	Fair Credit Reporting Act
	Fair Debt Collection Practices Act
Collection Methods
	Collection by Telephone
	Collection by Letter
Billing Services
Collection Agencies
Small Claims Litigation
	Who Can Use Small Claims
	How the Small Claims Process Works
Chapter 15	THE CLAIM
General Guidelines for Completing the CMS-1500 Form
Keys to Successful Claims
	First Key: Collect and Verify Patient Information
	Second Key: Obtain the Necessary Preauthorization and Precertification
	Third Key: Documentation
	Fourth Key: Follow Payer Guidelines
	Fifth Key: Proofread Claim to Avoid Errors
	Sixth Key: Submit a Clean Claim
HIPAA and the National Standard Employer Identifier Number
Claim Process
	Step One: The Claim Is Received
	Step Two: Claims Adjudication
	Step Three: Tracking Claims
	Step Four: Receiving Payment
	Step Five: Interpreting Explanation of Benefits
	Step Six: Posting Payments
	Time Limits
Processing Secondary Claims
Appeals
	Incorrect Payments
	Denied Claims
	Appealing a Medicare Claim
UNIT 5	ADVANCED APPLICATION
Chapter 16	THE ROLE OF COMPUTERS IN HEALTH INSURANCE
Impact of Computers on Health Insurance
HIPAA¿s Role in Electronic Transmissions
Electronic Data Interchange Electronic Data Exchange
	History of Electronic Data Exchange
	Benefits of Electronic Data Exchange
Electronic Claims Process
	Enrollment
	Electronic Claims Clearinghouse
	Direct Data Entry Claims
	Clearinghouse versus Direct
	Other Methods Available for Filing Claims Electronically
	Advantages of Filing Claims Electronically
Getting Started
	Obtaining Electronic Claim Capability
	Typical Hardware and Software Requirements
Medicare and Electronic Claims Submission
Additional Electronic Services Available
	Electronic Funds Transfer
	Electronic Remittance Advice
Electronic Medical Record
	Future of Electronic Medical Records
	Privacy Concerns of Electronic Medical Records
Chapter 17	REIMBURSEMENT PROCEDURES: GETTING PAID
Understanding Reimbursement Systems
	Types of Reimbursement
	Medicare and Reimbursement
	Systems for Determining Reimbursement
	Medicare¿s Transition to Resource-Based Relative Value Scale
	Other Reimbursement Systems
	Significance of Reimbursement Systems to the Health Insurance Professional
Peer Review Organizations and Prospective Payment System
Understanding Computerized Patient Accounting Systems
	Selecting the Right Billing System
	Managing Transactions
	Generating Reports
HIPAA and Practice Management Software
Chapter 18	HOSPITAL BILLING AND THE UB-04
Hospital versus Physician Office Billing and Coding
Modern Hospital and Health Systems
	Emerging Issues
Common Healthcare Facilities
	Acute Care Facilities
	Ambulatory Surgery Centers
	Other Types of Healthcare Facilities
Legal and Regulatory Environment
	Accreditation
	Professional Standards
	Governance
	Confidentiality and Privacy
	Fair Treatment of Patients
Common Hospital Payers and Their Claims Guidelines
	Medicare
	Medicaid
	TRICARE
	CHAMPVA
	Blue Cross and Blue Shield
	Private Insurers
The National Uniform Billing Committee and the UB-04
	Data Specifications
Structure and Content of the Hospital Health Record
	Standards in Hospital Electronic Medical Records
	Standard Codes and Terminology
Billing Process
	Informed Consent
	Hospital Charges
	Hospital Coding
	Manuals Used for Coding Hospital Claims
	New HIPAA Edit¿ICD-9 Procedure Codes
	National Correct Coding Initiative
	ICD-9-CM Procedure Codes and Medicare
Outpatient Hospital Coding
Hospital Billing and the UB-04: Understanding the Basics
	Standard Data Elements
	UB-04 Claim Form Completion Guidelines
Common Hospital Billing Errors
Electronic Claims Submission
HIPAA/Hospital Connection
The ANSI 835 Electronic Remittance Notices
Understanding the Full Circle Process: Guide to Medical Compliance
Career Opportunities in Hospital Billing
	Training, Other Qualifications, and Advancement
	Job Outlook
APPENDICES
Appendix A Sample Blank CMS-1500 Form (08/05)
Appendix B Sample Completed Claim Forms
Appendix C TANF Programs

Library of Congress Subject Headings for this publication:

Health insurance claims -- United States.
Insurance, Health -- United States.