AHEA 127 - Insurance & Reimbursement Methods

3 Credits: (3 lecture)

Course Description
This course focuses on principles of medical insurance and claims reimbursement. Topics include appropriate reimbursement procedures, claims processing, coordination of insurance benefits, and legal processing issues. The course will integrate the use of electronic claims submission, the appeals process, and documentation requirements.

Prerequisite AHEA 218.

A. Compare various medical insurance groups. 

B. Construct a CMS 1500 Claim Form. 

C. Prepare patient financial statements. 

D. Explain the concept of usual, customary, and reasonable fees. 

E. Cite reimbursement guidelines for inpatient and outpatient hospital services. 

F.  Discuss the appeals process for claims submission. 

G. Apply steps for obtaining an authorization or referral. 

Content
A. Medical insurance groups 

B. CMS 1500 claim form 

C. Patient financial statements 

D. Documentation guidelines 

E. Medical reimbursement 

F. Appeal process 

G.Authorization and referral 

 

Student Evaluation
Final grade will be determined from a series of classroom activities, case studies, assignments, quizzes and examinations. 

Grading Scale 

90-100% A 

80-89% B 

70-79% C 

60-69% D 

<59% F