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Healthcare Billing and Coding

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Question 1: Differences Between Individual Health Insurance and Group Health Insurance

Group health insurance is health insurance coverage supported by employers and other institutions that include labor unions, rural and customer health cooperatives. Green and Rowell (2014) argue that the group health insurance plan allocates the cost of the health insurance between group members in order to reduce the cost per an individual, and to provide a wide coverage. On the other hand, individual health insurance is a policy obtained b people or families who lack access to the group health insurance coverage. Furthermore, the individual health insurance policies are governed by individual states.

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Question 2: Commercial Claims Completion Process

While commercial claims completion is commonly understood globally, it is important to verify ever payer and to establish whether the payers require alternative information to be entered on the claim. Therefore, commercial claims completion process can vary in different situations where payers demand their specific CMS-1500 claims completion requirements.  In order to complete the CMS-1500, the patient’s information needed is often obtained from the patient’s registration form found in the chart (Johnson & Linker, 2015). According to Green and Rowell (2015), if the same payer gives both primary and secondary coverage, a single claim is usually made using the CMS-1500 claim instructions and data is integrated in Blocks 9 through 11d. Therefore, if a patient covered by a single commercial plan, the payer submits a single claim and information is provided in blocks 9 through 11.

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When a patient is covered by a small or larger employer group health plan (EGHP) on which the patient is designated as a policyholder, and the patent is also independent of  EHGP, the commercial claims is completed by acquiring a blank claim and creating  a copy of the CMS-1500 claim form ,and providing information on blocks 1 through 11. If a patient covered by larger employer group health plan (EGHP), and is a Medicare beneficiary, he or she adheres to the same completion claim process.

Following the fact that a child is covered by various plans, whereby the secondary payer might be different from the primary one, the commercial claims completion process occurs when a primary claim is succumbed to the secondary player (Johnson & Linker, 2015). Additionally, a new claim is generally created and given to the secondary payer, with information offered in Blocks 1a, 4, 7, 9throuhg 9 as well as 11  through 11d (Green & Rowell, 2015). Most importantly, a copy of primary payer’s payment is usually attached to the second claim.

Question 3: Reimbursement of Health Care Organizations by Disability, Automobile and Liability Insurance Policies

An automobile insurance policy entails a contract between a person and an insurance organization, in which the individuals reimburse a premium and the insurance company agrees to pay for certain car interrelated financial losses during the period of the policy. In particular, Green and Rowell (2015) illustrate the fact that automobile insurance policies comprise of medical payments and PIP coverage that normally repays up to a certain parameters, the medical expenses of wounded passage and driver in a vehicle that was associated with an automobile accident. Besides, the automobile insurance coverage might also cover pedestrians involved in an accident. Some of the medical expenses that can be reimbursed involve ambulance services, emergency division care, laboratory services, medical supplies, prescription medications, physical therapy and services offered b medical practitioners.

Disability insurance involves reimbursement for profits lost due to temporary or permanent illness and injury. Green and Rowell (2015) clarify that a disability claim commences on the period of disability, whereby the disability payer analyses an individual’s weekly income amount by employing a base period. Usually, the base period insurances 12 months and is allocated into four quarters. Moreover, in case patients are treated for disability detects, distinct patient records and financial records should be maintained to facilitate the insurance processing.

Liability insurance policy covers damages to a third party and triggered by the covered, object possessed by the insured, or on properties owned by the insured. Most importantly, the liability insurance claims are designated to cover the expenses of medical care for distressing injuries and lost remunerations. Green and Rowell (2015) reveal that health insurance reimbursements are secondary to liability cover.

1. Green, M. & Rowell, J. (2015). Understanding Health Insurance: A Guide to Billing and Reimbursement(12th ed.). Stamford, CT: Cengage Learning

2. Johnson, S. & Linker, R. (2015). Understanding Medical Coding: A Comprehensive Guide. Boston: Cennage Learning

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