HCR 202 Week 4 Benchmark Assignment—Reimbursement and Coverage Worksheet

HCR 202 Week 4 Benchmark Assignment—Reimbursement and Coverage Worksheet

HCR 202 Week 4 Benchmark Assignment—Reimbursement and Coverage Worksheet

Complete the Reimbursement and Coverage Worksheet.

Click the Assignment Files tab to submit your assignment.

Reimbursement and Coverage Worksheet

References: Ch. 8 and 12 of Medical Insurance: An Integrated Claims Process Approach (6th ed.)

Imagine you are a billing supervisor at a local health facility. You have been asked to determine the expected reimbursement and coverage determination on the following claims:

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires alot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you sahould get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• The is a great resource

You reviewed the claim 1500 form for patient Kevin Luke. You realize it is a new calendar year and he had not met his deductible. You had an authorization on file for treatment. Total billed charge amount is $1,100.00. His benefits are as follows:

PPO-Medical Care for diagnostic testing       In-network benefit preauthorization required. Pays at 100% after deductible is met.        Must meet deductible. Annual family deductible is $500.

Calculate the expected reimbursement from insurance and what the patient will owe.

You review the claim form for Lisa Smith for treatment of hyperglycemia. You discover she received treatment from a non-network provider. She has met her annual deductible. Total charges for the date of service are $170. The plan pays at usual and customary, which is exactly what was billed. Her benefits are as follows:

PPO-Medical care office visits           In-network benefit-Office visit copayment: $10.00   Out-of-network deductible and coinsurance of 20%.

Calculate the expected reimbursement from insurance and her coinsurance.

You are reviewing a claim for Maria Johnson, a 45-year-old who received a well check and flu shot from her in network provider. Her benefits are as follows:

PPO-Medical Care office visits          In-network benefit- copayment: Office visit $10.00 and Injections $25.00            Out-of-network Deductible and Coinsurance of 20%.

Mrs. Johnson called the office because she thought she had overpaid during her visit. What was Mrs. Johnson’s copay the date of the visit?

You are reviewing the vision exam benefits for Zach Bergman. He presented for an eye exam stating he needed new glasses. He had an examination 13 months prior and notes he can have an exam every year. His benefits are as follows:

PPO-Medical care office visits           In-network benefit-One vision exam every 2 calendar years.            Out-of-network Deductible and Coinsurance of 20%. Covered every 2 calendar years.

What is Mr. Bergman’s benefit?

Lisa Smith called your office noting she had to be transported to the hospital by ambulance while on vacation for food poisoning. She was concerned about what she will need to pay out-of-pocket. She was not admitted. Her benefits for emergency treatment are as follows:

PPO-Emergency treatment     In-network benefit-Copay $100. Waived if admitted. Ambulance services no charge.            Out-of-network Copay $100. Waived if admitted. Ambulance services no charge.

What should Lisa Smith expect to pay out-of-pocket?

Part B: Insurance Process Discussion

Choose one of the above cases and imagine the following scenario:

You received a call from the patient concerning their bill, and they would like to discuss it with you. You were asked a series of questions concerning insurance processes and medical reimbursement by the patient. As the billing expert you have a conversation addressing the patient’s billing questions and explaining the insurance process and steps you take. In 175 to 350 words, create a conversational dialog with the patient explaining the insurance process and why their claim was paid the way it was paid. Your conversation should include:

Explain how and why the patient’s insurance is verified.

Explain how to interpret the patient’s benefits for reimbursement using details from your selected case.

Explain possible pending insurance or patient actions relevant to your selected case.

Apply a professional and customer-oriented introduction and closure to the dialog.