Health Care

Explain the difference between Medicare Supplemental Insurance and Medicare Part B Explain how Medicare works as a secondary payer Describe the levels of the Medicare appeals process Explain the purpose of the Early Periodic Screening Diagnosis and Treatment program (EPSDT) Medicaid as the "payer of last resort Guidelines for billing patients for expenses not paid by Medicaid Managed Care Types of managed care organizations Reasons that a managed care plan might dis-enroll a member Documentation a provider should include to support a disenrollment request Purpose of re-insurance or stop-loss Why is it important? What are the consequences? Handling Grievances or complaints Primary Care Physician (PCP) Referrals to a specialist preauthorization/authorization second-opinion policies denial of services Transferring from one primary care physician (PCP), the patient’s gatekeeper, to another PCP How/Why individual providers terminate a contract Filing Insurance Claims Common errors Difference between clean claims, dirty (unclean) claims, and rejected claims Preventing omissions and mistakes      

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