FOR NYANYA (ONLY)

Hello Nyanya! This class is HLTH245 - Principals of Reimbursement Management. Week 4 - Billing Form for Adjudication assignment requested by July 18th.

Week 4 Introduction: Rarely does a submitted claim result directly in payment. Instead, the submission of a claim is only the beginning of a series of communications between the provider and the payer regarding the “payability” of the claim. This week, you will explore what happens once a claim is submitted, this is called adjudication. You will consider factors that impact a decision of a healthcare provider to participate in a particular payer’s plan and share your insights in a discussion.  As consumers of healthcare each of us has to make a decision about what provider we choose. Whether or not a provider participates with the insurance payer, may help you make that decision. From your role as a healthcare provider, there may be reasons why you choose or not choose to participate in a particular insurance provider. It is important to understand that there are two sides to this issue. Week 4 Objectives: Compare and contrast drawbacks and benefits of participatory versus non-participatory healthcare providers.

Required Resource:

ISBN: 978-0-07-351371-3

Valerius, J., Bayes, N., Newby, C., Blowchowiak, A. (2012). Medical Insurance, an Integrated Claims Process Approach. (6th Ed.), New York, NY: McGraw-Hill Publishers.

• Chapter 13
• Chapter 14

ISBN: 978-0-7637-5964-3

Valerius, J., Bayes, N., Newby, C., Blowchowiak, A. (2012). Medical Insurance Workbook. New York, NY: McGraw-Hill Publishers.

Written Assignment - Billing Form for Adjudication

• Attached Files
• Billing Form.pdf (86.314 KB)

Lead in:

Adjudication is a payer-side process that “judges” whether the claim is considered payable. As a reimbursement professional, you will need to be thoroughly familiar with the five steps in the process and the analysis that occurs in each in order to be prepared to respond to payer rejections. Your goal is to review the billing form and note areas that may prevent the healthcare provider from being paid.

To prepare for this assignment:

With this in mind,

Prepare a 1-2 page APA paper, title and references page. No specific word count. Using the claim form provided that has been billed to a primary payer, answer the following questions:

• What are the correct coding guidelines to be used with this claim?
• How should services be bundled?
• Are the primary and secondary diagnoses correct?
• Has the setting for treatment been identified?
• Are there other issues that need to be addressed to prevent this claim from being paid?

Submit to the Written Assignments section of the Learning Hub by Day 7.