CRS 110 Medical Insurance & Reimbursement Systems

Outcomes

Identify types of insurance plans. Identify models of managed care. Discuss workers compensation as it applied to patients. Describe procedures for implementing both managed care and insurance plans. Discuss utilization review principles. Discuss referral process for patients in a managed care program. Describe how guidelines are used in processing an insurance claims. Compare processes for filing insurance claims both manually and electronically. Describe guidelines for third party claims. Discuss types of physician fee schedules. Describe the concept of RBRVS. Define Diagnosis Related Groups DRGs. Apply both managed care policies and procedures. Apply third party guidelines. Complete insurance claim forms. Obtain precertification including documentation. Obtain preauthorization, including documentation. Verify eligibility for managed care services. Demonstrate assertive communication with managed care and or insurance providers. Demonstrate sensitivity in communicating with both providers and patients. Communicate in language the patient can understand regarding managed care and insurance plans.