MEDA 149 - Medical Insurance Procedures for Medical Assisting

1. Interpret information on an insurance card
2. Verify eligibility for services 
3. Identify:
   • types of third-party plans
   • steps for filing a third-party claim
4. Identify processes for:
   • verification of eligibility for services
   • precertification/preauthorization
   • tracking unpaid claims
   • claim denials and appeals
5. Obtain precertification or preauthorization with documentation.
6. Complete an insurance claim form.
7. Identify the purpose and components of the Explanation of Benefits (EOB) and Remittance Advice (RA) Statements.
8. Assist a patient in understanding an Explanation of Benefits (EOB).
9. Identify managed care requirements for patient referral.
10. Identify fraud and abuse as they relate to thirdparty reimbursement.
11. Define the following:
    • bundling and unbundling code
    • advanced beneficiary notice (ABN)
    • allowed amount
    • deductible
    • co-insurance
    • co-pay
12. Identify the current procedural and diagnostic coding systems, including Healthcare Common Procedure and Diagnostic Coding Systems II (HCSPCS Level II)
13. Perform Procedural and Diagnostic coding
14. Identify the effects of:
    • upcoding
    • downcoding
15. Define and utilize medical necessity guidelines.

1. Insurance coverage and verification process
2. Submitting in third-party reimbursement claims
3. Explanation of Benefits
4. Procedural and diagnostic coding
5. Fraud and abuse related to third-party reimbursement
6. Managed care, Medicare, Medicaid and workmen’s comp and disability

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