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Medical Insurance Billing Manual

Medical Insurance Billing Manual

Medical Insurance Billing Manual

Healthcare insurance in the United States includes Health Maintenance Organizations, traditional fee-for-service health insurance plans, and preferred provider organizations (Harris, 2011). Traditional fee-for-service health insurance plans are often expensive compared to those with an income lower than the average income in the United States. Preferred Provider Organizations provide lower co-payments but allow users more flexibility in selecting a provider because they give users a list of providers to choose from. Health Maintenance Organizations provide a limited choice of healthcare providers but offer lower co-payments. It also covers more preventative care costs. Medical insurance is categorized into Medicaid, commercial insurance, Medicare, Blue Shield, CHAMPUS, Blue Cross, HMOs, and worker’s compensation (Rice, 2021). Individuals can also choose government insurance programs and individual and group insurance plans. Blue Cross is used for nursing homes, inpatient hospitals, and other healthcare facilities, while Blue Shield is used for outpatient services. The difference between the Blue Shield and Blue Cross is that the Blue Cross aims to gain profit while the Blue Shield is a non-profit program. The main programs under Blue Shield are Medicaid, Medicare, and CHAMPUS. All the Blue Shield plans have comprehensive benefits and various wellness programs to help users get healthier and save money. UCR providers and indemnity providers offer them.UCR and indemnity providers have contracts with Blue Shield to see patients, but the physicians decide whether to charge the patient the required amount or file an insurance claim (Rice, 2021). Choosing the right health insurance plan is a delicate process that requires considering various aspects. One of the things to consider is whether the plan gives you the right to see any doctor and visit any clinic, pharmacy, or hospital. The second thing is whether specialists such as dentists and eye specialists are covered. The third thing is whether the plan covers unique treatments or conditions such as physical therapy, psychiatric care, and pregnancy. The fourth thing is whether the plan covers nursing home care and medications that a physician might prescribe. The fifth thing is whether there are any co-payments or deductibles, and the most you will have to pay out of your pocket to cover expenses.

Summaries of each type of insurance


Medicaid is a federal-state health insurance program serving low-income people of all age brackets. It pays for the costs incurred by a patient in medical expenses. Most Medicaid beneficiaries are covered under privately managed care plans. At the same time, in some states, Medicaid programs pay doctors, hospitals, nursing homes, and other healthcare providers for covered services provided to eligible patients. Patients may, however, be required to make a small payment. States must ensure that Medicaid programs cover certain mandatory services such as nursing facility services, physician and hospital care, x-ray and laboratory services, and home health services. Federal rules also require states to offer a more comprehensive set of services identified as the Early and Periodic Screening, Diagnostic, and Treatment benefits for children below 21 years.


Medicare is a federal health insurance program that includes paying medical bills from trust funds covered individuals have paid into. It covers individuals aged 65 regardless of income, younger disabled individuals, and patients undergoing dialysis (Rizzo & Kukowski, 2013). Patients pay Part of the medical costs through deductibles. Individuals using the program must pay small monthly premiums for coverage unrelated to the hospital. Medicare includes different parts, mainly parts A, B, C, and D (Rizzo & Kukowski, 2013). Part A includes hospital insurance, covering inpatient care in a skilled nursing facility, hospital stays, and home health care. Part B includes medical insurance covering certain doctors’ services, preventive care, medical supplies, and outpatient care. Part C covers Medicare Advantage plans such as private private plans and HMOs.Part D covers prescription drug coverage and helps cover the cost of prescription drugs (Rizzo & Kukowski, 2013).

The eligibility for Medicare drug coverage requires joining a Medicare-approved plan offering drug coverage. Enrolling in Medicare includes an initial enrolment period and special enrolment periods. The initial enrolment period is when an individual first becomes eligible for Medicare. The period runs for seven months, and individuals can enroll in original Medicare Part B or A. Individuals can also enroll in Part D if they are already enrolled in Original Medicare (Rizzo & Kukowski, 2013). An individual can alternatively choose a Medicare Advantage plan through a private insurer covering both Part A and B services. After the initial enrolment period ends, an individual can make enrolment changes during the General enrolment period or the Medicare Open Enrolment unless they qualify for a particular enrolment period (Rizzo & Kukowski, 2013). A particular enrolment period occurs when an individual is allowed to enroll in the Medicare program or other Medicare options outside of the annual or initial open enrolment periods.

Umbrella Insurance

Umbrella insurance is extra insurance protecting existing limits and coverages of other policies (Morrisey, 2013). It can cover property damage, injuries, personal liability, and certain lawsuits. Most health insurance policies under umbrella insurance have a coverage requirement that individuals must purchase in their health policy.

Worker’s compensation

This is a government-mandated system that focuses on paying monetary benefits to workers who become disabled or injured in the course of their employment. Individual states often handle worker’s compensation in the United States. Identical injuries can be compensated differently based on where the worker lives, making it essential to review local compensation statutes (Boggs, 2013). The United States Department of Labor has an Office of Worker’s Compensation Program, but it is only responsible for federal employees’, coalminers’, and longshoremen’s compensation policies.

Health Maintenance Organizations

Health Maintenance Organizations are managed care health insurance plans featuring a network of healthcare providers that treat patients for a prepaid cost (Morrisey, 2013). The plan combines care delivery and financing, thus providing an incentive to offer cost-efficient quality care. They offer health insurance coverage for an annual or monthly fee. Member coverage is limited to medical care provided through a network of healthcare providers and doctors under contract with the Health maintenance organizations. The contracts help ensure that premiums are lower than conventional health insurance because the health care providers have the advantage of receiving patients regularly. Healthcare entities that enter into a contract with the Health Maintenance Organizations are paid a fee that is agreed upon to provide a range of services to subscribers. The payment allows the HMOs to retain high-quality care at a lower price.


Tricare is a healthcare program that focuses on the United States military and is managed by the government. It includes coverage plans providing healthcare for many former and current service members and their families. The Pentagon’s Defense Health Agency manages it. The program is divided into various coverage programs covering National Guardsmen, active-duty families, military retirees, reservists, and their families. The programs include Tricare Reserve Select, Tricare Prime, Tricare Dental Plan, Tricare Select, Tricare Young Adult, and Tricare for Life. In Tricare Select, users can select their preferred primary care manager and self-refer to healthcare providers. Tricare Prime operates like a Health Maintenance Organization where users are assigned a primary care manager and are required to get referrals to access specialty care. The costs of a user rely on the status of military service. Tricare for Life includes supplemental health coverage for retirees and their spouses over 65. Retirees must be enrolled in Medicare Part B and pay the monthly premiums for Part B to use Tricare for Life. United Concordia manages the Tricare Dental plan, which can be purchased by Guard and Reserve members, active-duty family members, and their families.


The Civilian Health and Medical Program of the Uniformed Services(CHAMPUS) is a health program funded by the federal government that provides medical care for beneficiaries supplemental to the medical care available in the United States public health and military facilities—all beneficiaries using CHAMPUS switch to Medicare at 65 years.

The primary requirements for billing for each type

Medicaid mainly targets low-income families, pregnant women, children, people with disabilities, and the elderly. Medicaid beneficiaries must be residents of the state where they are receiving Medicaid. They must be qualified non-citizens of the United States or citizens of the United States. Medicare requirements, on the other hand, include being a United States citizen or a permanent legal resident living in the United States for at least five years, being a government employee or a spouse of a government employee, being a retiree who has not paid into Social Security but paid Medicare payroll taxes while underemployment and is an individual receiving social security or railroad retirement benefits or have worked long enough to gain eligibility for those benefits but are not yet getting them(Rizzo & Kukowski, 2013). Other primary requirement for Medicare eligibility is being entitled to Social Security disability benefits for at least 24 months, having Lou Gehrig’s disease, receiving a disability pension from the Railroad Retirement Board and meeting specific conditions, and having permanent kidney failure requiring a kidney transplant or regular kidney dialysis (Rizzo & Kukowski, 2013). Individuals can also buy Medicare benefits in various ways. One of them is paying premiums for Part A. The amount that needs to be paid depends on how long a person has worked. The longer a person works, the more credits they earn. Work credits are paid based on an individual’s income, and the income required to earn credit changes annually. The second way is paying the same monthly premiums for Part. People with higher incomes pay more. The third way is paying the same monthly premium for Part D (Rizzo & Kukowski, 2013). The main requirement for umbrella insurance is buying a minimum amount of property or auto insurance liability coverage before adding an umbrella coverage. Worker’s compensation requirements include an injured worker being classified as an employee, the employer being insured, and the injury being work-related. Individuals may not qualify for worker’s compensation if they are domestic workers, leased or loaned employees, farm and agricultural workers, undocumented workers, and seasonal or casual workers.

One of the requirements for Health Maintenance Organizations is paying an annual or monthly premium to access medical services in the organization’s network of healthcare providers. Individuals insured under Health Maintenance Organizations may have to work or live in the network area covered by the plan (Green & Rowell, 2011). When subscribers receive urgent care while they are away from the HMO network area, the HMO may cover the expenses, but subscribers who receive out-of-work, non-emergency care hmustpay for it (Morrisey, 2013). The main requirement for Tricare eligibility is listed in DEERS as eligible for military health care benefits. Other requirements include being a retired or active duty uniformed service member, being a Reserve or National Guard member or a spouse of either of them, being a spouse or child of a retired or active duty uniformed service member, being a former spouse of a military member, being a survivor of a deceased military member, being a recipient of a medal of honor and being registered in the Defense Enrollment Eligibility Reporting System. The main requirement for CHAMPUS eligibility is being a child or spouse of a veteran who a VA regional officer has rated as totally and permanently disabled for a disability arising from their service as some military personnel.

Note inpatient or outpatient differences where appropriate.

The difference between outpatients and inpatients in all medical insurance is how long a patient must stay in the healthcare facility. The outpatient diagnosis report includes services on a patient’s extended stay, while the inpatient diagnosis report includes a patient’s treatment in a single visit. If an individual is hospitalized and undergoes surgery within 24 hours, the operations may qualify under treatments in the daycare category for their health insurance coverage. Hospitalization extending beyond 24 hours is considered to be outpatient. In worker’s compensation, an individual is rconsideredan inpatient if they must stay in a healthcare facility for two nights. The inpatient bill should be submitted within thirty days after being discharged. Worker’s compensation outpatient services require patients to fill out some paperwork when they visit the clinic. This form indicates a patient’s medical records every time they visit the clinic. Tricare covers outpatient and inpatient psychological and mental care. It covers inpatients if it is a psychiatric or medical emergency or an immediate hospital admission. If a patient has a mental disorder, it may include detoxification, stabilization, and other medical complications. It covers outpatients with psychiatric disorders, and patients are not required to be in a hospital full-time.

Please explain how to determine from the patient which type they subscribe to

There are two ways to determine the type of insurance a patient has subscribed to. One of them is looking at the insurance card. Insurance cards state the insurance company and the phone numbers to call. You can call the number provided to get a summary of plan benefits. Most commercial insurance companies also have websites with details about enrolled providers. The second way is logging in to the patient’s healthcare government account. The patient’s name can be selected at the top icon on the patient’s coverage and applications. Existing applications can outline the patient’s insurance types and coverage summary.


Boggs, C. (2013). The insurance professional’s practical guide to workers’ compensation.

Green, M., & Rowell, J. (2011). Understanding health insurance: A guide to billing and reimbursement.

Harris, T. F. (2011). Health care coverage and financing in the United States. ACTEX Publications.

Morrisey, M. A. (2013). Health insurance in the United States. Handbook of Insurance, 957-995.

Rice, T. (2021). United States. Health Insurance Systems, 191-222.

Rizzo, V. M., & Kukowski, R. (2013). Medicaid and Medicare. Encyclopedia of Social Work.


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To properly code a bill for medical necessity, it is essential to understand different plans and the requirements for billing each. They all indeed use the ICD-10-CM diagnosis coding system, the CPT procedure coding system, and the CMS-1500 form, but each type of carrier has specific requirements for a clean bill.

Medical Insurance Billing Manual

Medical Insurance Billing Manual

Create a billing manual constructed of summaries of each type of insurance.
Include the significant requirements for billing for each type.
Note inpatient or outpatient differences where appropriate.
Please explain how to determine from the patient which type they subscribe to.
Submission Details:
Submit this topic as an 8- to 10-page Microsoft Word document. Use APA standards for citations and references.
Cite a minimum of three outside peer-reviewed sources to support your assertions.

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