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Elsevier Patient Financial Services Searchable Document

Course: Health Plans and Payer Types

Abstract Learning Objectives Table of Contents

Lesson: An Overview of Health Plans and Payer Types

This lesson provides patient financial services staff, and others involved with the facility's revenue cycle process, with an overview of the health insurance programs and health plans used to pay patients' medical bills. It defines common health insurance terms and describes the main features of popular health insurance programs, such as Medicare, Medicaid, commercial health insurance, self-pay, and the marketplace exchanges. It also introduces indemnity and fee-for-service (FFS) health insurance plans, as well as various forms of managed care plans, including: •Health maintenance organizations (HMOs) •Point-of-service organizations (POS) •Preferred provider organizations (PPOs) •Exclusive provider organizations (EPOs) •High-deductible health plans (HDHPs) •Health savings accounts (HSAs) The lesson explains the coordination of benefits (COB) process used to determine the primary payer in situations in which the patient has more than one insurer that might be responsible for paying the patient's bill.

• Define common health insurance terms used in insurance contracts and interactions with health insurers.

• Identify the key features and characteristics of common health insurance programs, health plans, and types of insurers.

• Differentiate between the various types of health plans and insurers.

• Select the correct primary payer for common situations in which the patient's care is covered by more than one insurer.

• Introduction to Health Insurance

• Role-Related Insurance Terms

• Difference Between a Health Plan and a Payer

• How Health Insurance Works

• Terminology Related to Cost-Sharing

• Terminology Related to Patient Bills

• Knowledge Check: Understanding Health Insurance Cost-Sharing Terminology

• Knowledge Check: Understanding Health Insurance Terminology Related to the Patient’s Bill

• Health Plan Coverage

• Noncovered Services

• Medical Necessity

• Notice of Noncoverage

• Compliance

• Knowledge Check: Coverage, Medical Necessity, Notices of Noncoverage, and Compliance

• Medicare

• Medicare Supplemental Insurance (Medigap)

• Medicaid

• Knowledge Check: Differentiating Between Medicare and Medicaid

• Government-Sponsored Programs

• Employer or Other Organization-Sponsored Health Insurance Programs

• Market Exchanges

• Other Insurance Programs

• Self-Pay

• Health Insurance Scenarios


• Knowledge Check: Identifying the Type of Insurance

• Patients with More Than One Insurer or Responsible Party

• Coordination of Benefits

• Coordination of Benefits Guidelines

• Knowledge Check: Determining the Primary Payer

• Provider Types

• Knowledge Check: Identifying Provider Types, Part 1

• Knowledge Check: Identifying Provider Types, Part 2

• Health Plan Types

• Managed Care Strategies

• Knowledge Check: Identifying Characteristics of Different Types of Health Plans, Part 1



Lesson: Health Plans and Payer Types: Original Medicare

This lesson provides an overview of the Original Medicare program (also called traditional Medicare or fee-for-service Medicare), and introduces the new Medicare cards and identification numbers. It defines the components of the program—Part A and Part B—and explains how Part C and Part D are separate programs. It describes the role of the Medicare administrative contractors (MACs) in the processing and payment of claims, as well as the procedures used by hospital revenue cycle staff to determine financial responsibility for Medicare patients, including:

• Identify the main characteristics of the four different parts of the Medicare program.

• Identify who is eligible to be covered by Medicare.

• Recall the role of the Medicare administrative contractor.

• Demonstrate knowledge of the purpose and use of the MSPQ and Notices of Noncoverage.

• Define medical necessity as it pertains to Medicare coverage.

• Recognize the differences between the old and the new Medicare

• Introduction to Medicare

• Medicare Part A: Eligibility

• Medicare Part A: Deductibles and Coinsurance

• Medicare Part B

• Medicare Part C

• Medicare Part D

• Medigap Insurance

• Medicare Case Examples

• Medicare Claims Processing

• Knowledge Check: Medicare’s Parts Review

• Medicare Health Insurance Cards


• Completion of the Medicare Secondary Payer Questionnaire (MSPQ)

• Determination of medical necessity

• Issuing of noncoverage notices, including the Advance Beneficiary Notice of Noncoverage (ABN) and the Hospital Inpatient Notice of Noncoverage (HINN)

This lesson also helps staff understand how hospitals interact with the Medicare program, especially those who work in the insurance verification unit, scheduling, registration, or Patient Access. It is also a primer for the billing department, collections, and others who explain and answer questions about Medicare. The purpose of this lesson is to give the learner an overview of the Medicare program as it relates to the hospital revenue cycle, especially Patient Access.

insurance cards and identification numbers.

• Medicare Identification Numbers Current and Future

• Accurate Patient Name and Insurance Numbers

• Current Medicare Health Insurance Claims Number (HICN) and Suffixes

• New Medicare Beneficiary Number (MBI) Format

• Medicare Railroad Card

• Knowledge Check: Identification Review

• Medicare Secondary Payer (MSP) Rules

• MSP Questionnaire

• Knowledge Check: MSP Questionnaire

• Preventive Services and Screenings

• Examples of Covered Preventive and Counseling Services

• Medicare Hospice Benefits

• Services that are Never Covered

• Knowledge Check: Medicare Coverage

• Medical Necessity

• Coverage Policies

• Knowledge Check: Identifying Type of Coverage Policy

• Notifying the Patient that Medicare May Not Pay

• Examples of Different Notices of Noncoverage

• Purpose of a Notice of Noncoverage

• Examples of Situations that Require a Notice of Noncoverage

• Knowledge Check: Types and Purpose of Notices of Noncoverage

Lesson: Medicare Managed Care (Medicare Advantage)

This lesson informs Patient Access staff and others involved in the revenue cycle process about the main features and characteristics of Medicare's Part C managed care

• Define Medicare Advantage (MA) and recall information about its expected future growth.

• Introduction to Medicare Advantage • Enrollment and Expected Growth of Medicare

Advantage Plans • Knowledge Check: Medicare Advantage Overview


insurance, also known as the Medicare Advantage (MA) program, so that they can correctly identify MA patients in the registration and billing systems. It outlines the main characteristics of the different types of Medicare Advantage (MA) plans, and reviews common terminology used when describing them. It also defines "shadow billing" and explains why it is necessary, and when shadow bills must be sent. The lesson touches on coordination of benefits (COB) and the fact that Medicare managed care plans, like Original Medicare, are payers of last resort.

• Recall common terminology associated with Medicare Advantage.

• Identify the common types of MA plans and the key element of risk related to them.

• Demonstrate knowledge of the process Patient Access uses to determine whether a patient is enrolled in Original Medicare or Medicare Advantage.

• Define the term shadow billing and the role of Patient Access in the process.

• Medicare Advantage Plan Basics • Types of Medicare Advantage Plans • Health Maintenance Organization (HMO) Plans • Preferred Provider Organizations (PPO) • Special Needs Plans (SNPs) • Private Fee-for-Service (PFFS) • Medical Savings Account (MSA) Plans • Knowledge Check: Types of Medicare Managed

Care • Identifying the Type of MA Plan • Medicare Advantage Cards • Knowledge Check: MA Insurance Cards • Case Scenario: Medicare Advantage Verification • Case Scenario Discussion • Knowledge Check: Insurance Verification • Shadow Billing Requirements • Coordination of Benefits • Knowledge Check: Shadow Billing and COB •

Lesson: Medicaid and Medicaid Managed Care

This lesson introduces Patient Access staff and others working in the revenue cycle process to Medicaid and Medicaid managed care plans. It identifies the main characteristics of each type of plan and defines terms commonly used to describe Medicaid policies and patient payer status, such as dual-eligible and the spend down rule. Lastly, the lesson includes information on the Children's Health Insurance Program (CHIP) and touches on coordination of benefits (COB) between Medicaid and other insurers.

• Identify characteristics of the different types of Medicaid plans and CHIP.

• Define common terms associated with Medicaid and Medicaid managed care plans.

• Demonstrate knowledge of who is eligible for Medicaid, Medicaid managed care, and CHIP programs.

• Recall key factors to consider when registering patients who may be eligible for Medicaid.

• Medicaid Overview • Children’s Health Insurance Program (CHIP) • Knowledge Check: Medicaid and CHIP • Medicaid Coverage • Knowledge Check: Mandatory and Optional

Medicaid Coverage Review • Medicaid Eligibility • Other Eligibility Requirements • Retroactive Eligibility • Presumptive Eligibility for Medicaid • Case Study Example: Presumptive Medicaid • Affordable Care Act and Expansion of Medicaid • Knowledge Check: Benefits, Eligibility, and

Enrollment Review


• Medicaid and CHIP Options • Managed Care Organizations (MCOs) • Referrals and Preauthorizations • Knowledge Check: Features of Medicaid Managed

Care • Medicaid Cards • Collecting Medicaid Information from the Patient • Insurance plan Codes • Medicaid Coordination of Benefits (COB) • Case Study Example: Presumptive Medicaid • Knowledge Check: Insurance Plan Code Selection • Patient Spend Down • Case Study Example: Spend Down not Met • Case Study Example: Spend Down Met • Patient Cost Sharing and Out-of-Pocket Expense • Dual-Eligible • Knowledge Check: Medicaid Terms and

Descriptions

Lesson: Veterans Affairs (VA), TRICARE, and CHAMPVA

This lesson defines three broad programs that offer healthcare coverage for active and retired military personnel, their spouses and children, and disabled veterans:

• Veterans Affairs (VA) healthcare system

• TRICARE • Civilian Health and Medical Program

of the Department of Veterans Affairs (CHAMPVA)

It lists types of programs and health plans offered and defines common terms, such as "service-connected," that are associated with each.

• Differentiate between the Veterans Affairs (VA) healthcare benefits program, TRICARE, and CHAMPVA.

• Identify key features of the various military health insurance programs and plans.

• Recall common terminology connected with the military health insurance programs.

• Distinguish a service-connected condition from a non-service-connected condition.

• Demonstrate knowledge of the financial risk involved in not obtaining preauthorizations prior to rendering nonemergent care to veterans, military personnel, and their families.

• Overview of Military Health Insurance Programs • Knowledge Check: Military Healthcare Program

Characteristics • Introduction to Military Healthcare Coverage in

Nonmilitary Facilities • Military Coverage Eligibility and Relationship

Terminology • Knowledge Check: Military Healthcare Coverage

Review • VHA: Growing Number of Veterans Utilizing VA

Health Services • VHA: Veterans Administration Centers Located

Across the Country • VHA: Identification Cards • VHA: Defining Types of Conditions and Disabilities


The purpose of the lesson is to ensure that Patient Access staff and others involved in the revenue cycle process understand how the VA health system, TRICARE, and CHAMPVA work, and how they coordinate with non-VA facilities and other insurers to render and pay for care. This lesson also provides details about the administrative aspects of the three programs and explains which programs need prior authorization.

• VHA: Wait Times and Access Obstacles • VHA: Veterans Choice Program Eligibility • VHA: PC3/Choice Contractors • Knowledge Check: VHA Administration • VHA: Prior Authorizations for Scheduled Care • VHA: Provider’s Authorization Notice • VHA: Emergency Care at a Non-VA Community

Facility • VHA: Coordination of Benefits for Veterans with

VA-Authorized Services • VHA: Coordination of Benefits for Unauthorized

Services • VHA: Veterans Benefits with medicare and

Medicaid • VHA: Coordination of Benefits in Emergency

Situations • Knowledge Check: VHA Program Requirements • Tricare: Introduction • Tricare: Eligibility • Tricare: Coverage • Tricare: Prime Plan Options • Tricare: US Family Health Plan • Tricare for Life and Other Plan Options • Other Tricare Plans • Knowledge Check: Tricare Plan Options • Tricare: Identification Cards • Tricare Contractors • Tricare: Referrals and Prior Authorization • Tricare: Coordination of Benefits (COB) • Knowledge Check: Tricare Requirements • CHAMPVA: Eligibility • Coordination of Benefits in Emergency Situations • CHAMPVA: Insurance Cards • CHAMPVA: Coordination of Benefits (COB)


• CHAMPVA: Prior Authorization • Knowledge Check: CHAMPVA Review • Best Practices for Processing Patients Covered by

a Military Program

Lesson: Commercial, PPOs, and HMOs

This lesson gives an overview of commercial health insurance. It describes the following types of commercial health insurance plans and their features:

• Indemnity or fee-for-service (FFS) plans

• Health maintenance organizations (HMOs)

• Point-of-service (POS) plans • Preferred provider organizations

(PPOs) • Exclusive provider organizations

(EPOs) • High-deductible health plans

(HDHPs) • Health Savings Accounts (HSAs)

The lesson also describes the agreements or contracts that providers negotiate with health insurers. It explains how the contract terms determine how much and when a hospital receives payment, and what requirements the providers must meet to be paid. This lesson will help Patient Access staff and others involved in the revenue cycle process understand the different types of commercial health plans and what they need to know about each to correctly identify the patient's specific insurer and

• Differentiate among the types of commercial health plans.

• Recognize key features of the different types of commercial health plans.

• Recall commonly used insurance terms.

• Identify which insurer is the primary payer in situations in which coordination of benefits is required.

• Introduction to Commercial Health Insurance • Interchangeable Insurance Terms • Purchasers of Commercial Insurance • Rising Out-of-Pocket Expenses • Health Plan General Features • Keeping Track of Each Insurer’s Contract

Requirements • Contract Details • Knowledge Check: Commercial Health Insurance

Review • Indemnity or “Fee-for=Service” Health Plans • Managed Care Organizations (MCOs) • Health Maintenance Organizations (HMOs) • Other Types of Managed Care Plans • High-Deductible Health Plans and Health Savings

Accounts • Self-Insured Plans • Summary of Characteristics of Various Types of

Health Insurance Models • Knowledge Check: Review of Commercial Health

Plan Models • Example of a Large Nationwide Insurer • Examples of Blue Cross Insurance Codes • Knowledge Check: BCBS Review • Insurance Card Basics • Knowledge Check: Commercial Insurance Card

Information • Coordination of Benefits


type of health plan. This in turn will help them to anticipate what services are covered by the patient's health plan and what the insurer's requirements are for getting the claim paid.

• COB Rules Used for an Adult with Commercial Insurance

• COB for Commercial Insurance and a Government Payer

• COB for Children or Dependents Covered by One or More Commercial Health Insurance Plans

• Case Study: Birthday Rule Review • Coordinating Paying the Bill • Knowledge Check: COB Review • Affordable Care Act (ACA) and Commercial Health

Plans • Group Health Plans Versus the Insurance

Exchanges • COBRA and HIPAA • Case Scenario: COBRA

Lesson: Marketplace Exchanges and the ACA

This lesson provides an overview of: • Health insurance provisions in the

Affordable Care Act (ACA) • The types of insurance plans and

cost-sharing options available in the Health Insurance Marketplace

• The premium tax credit and extra savings program associated with them

The impact the ACA has had on the role and job function of the Patient Access staff and others involved in the revenue cycle process is also discussed.

• Define the ACA and common terms associated with it that are used within the hospital revenue cycle.

• Recognize key features of health insurance plans purchased through the ACA.

• Demonstrate knowledge of the ACA's four cost-sharing options, premium tax credit, and the extra savings program.

• Identify ways the Patient Access staff roles have changed as a result of the ACA.

• Recall why the electronic data interchange (EDI) 270-271 transactions are important in Patient Access.

• Introduction to the Affordable Care Act • Knowledge Check: Affordable Care Act Overview • Marketplace Exchanges • Navigators and Certified Application Counselors • Essential Health Benefits • Health Plan Choices • Health Plan Cost-Sharing Options • Catastrophic Health Plans • Knowledge Check: Marketplace Review • Patient Access Staffs” Role in Explaining Cost

Sharing • Cost-Sharing Programs • Deductibles • Copayments • Coinsurance • Out-of-Network Deductibles, Coinsurance, and

Maximum Amounts • Marketplace Scenario


• Knowledge Check: Cost-Sharing • Insurance Eligibility Verification • Verifying Insurance Eligibility and Coverage • 90-Day Grace Period to Pay Premiums • Grace Period: Best Practice • Grace Period: Case Scenario • Knowledge Check: 90-Day Grace Period and EDI

Transactions

Lesson: Self-Pay and Underinsured

The purpose of this lesson is to inform Patient Access and other revenue cycle staff of the issues surrounding obtaining payments from self-pay patients who are uninsured, or from patients who are underinsured or have high-deductible health plans (HDHPs). It explains the responsibility hospitals have in providing financial counseling and assistance to these patients, and it provides examples for how to:

• Estimate a patient's out-of-pocket costs

• Calculate discounts • Advise patients on payment options

and how to apply for assistance • Perform point-of-service (POS)

collections

• Identify the types of self-pay patients.

• Define underinsured and recognize the connection to high-deductible health plans.

• Identify factors that contribute to the number of self-pay and underinsured patients.

• Demonstrate knowledge of topics that revenue cycle staff need to communicate to self-pay and underinsured patients about their health insurance and out-of-pocket costs.

• Recall best practices for communicating with self-pay and underinsured patients.

• Recognize if your hospital is affected by the IRS 501(r) financial assistance regulations.

• Self-Pay Patients • Factors Influencing the Number of Uninsured and

Underinsured Patients • Case Scenario: Encounter with a Self-Pay Patient • Patient Access Staff’s Role in Communication with

Self-Pay Patients • Working with the Self-Pay Patients • Knowledge Check: Self-Pay • Discussing patient Financial Responsibility • Price Shopping • Providing Prices • Calculating Discounts • Knowledge Check: Prices and Discounts • Challenges to Estimating Patient Costs • Giving Estimates • Determining Cost-Share for Patient with a HDHP • Determining Cost-Share for Self-Pay Patients • Estimating Cost for Elective or Cosmetic

Procedures for a Self-Pay Patient • Knowledge Check: Estimating Costs Review • Regulations for Not-for-Profit Hospitals • Financial Assistance Policy • Example of a Financial Assistance Policy in Action • Communicating Financial Assistance Policy to

Patients


• Determining Eligibility for Other Programs • Knowledge Check: Common Financial Assistance

Policy Requirements and Practices • Collecting Patient Cost-Shares • Self-Pay or Underinsured Patient Interactions • Interacting with Patients • Best Practice Case Scenario • Knowledge Check: Point-of-Service Collection

Review

Lesson: Workers' Compensation and Other Types of Liability Insurance

This lesson explains what liability insurance is and the types of injuries and other conditions that are covered by it. The lesson outlines the process used to determine if a liability insurer is responsible for paying for a patient's care and identifies the documents and information needed to assign a liability insurer as the primary payer and process a claim. This lesson describes the following types of third-party liability and compensation payers:

• Workers' Compensation • Crime victim compensation • Other liability insurers that cover

injuries and other conditions that occur in the home or in a place of business, or result from the use of a defective product or service.

The purpose of the lesson is to ensure that Patient Access staff and others in the revenue cycle who are involved with the identification of liability cases can identify the correct payer and collect the documents

• Demonstrate knowledge of the steps and best practices used to determine who is liable and responsible for payment in a liability case.

• Define Workers' Compensation. • Recall information that must be

collected during registration for Workers' Compensation.

• Identify the factors to consider when dealing with Workers' Compensation.

• Identify key features of crime victim compensation and other liability insurers

• Introduction to Liability Payment Situations • Gathering Information Needed to Determine Who

is Liable • Determining Which Third-Party is Responsible for

Payment • Knowledge Check: Liability Determination Process • Introduction to Workers’ Compensation • Incident or Accident Reports • Injured Workers Who Seek Treatment Without

Authorization • Case Example: Contacting Employer for

Authorization • Registration Best Practice • Best Case Scenario • Typical Case Scenario • Knowledge Check: Worker’s Compensation • Case Scenario: Obtaining Missing Worker’s

Compensation Information • Scheduled Services • Payer Responsibility • Knowledge Check: Best Practices • Other Accidents • Payer Liability Limits • Crime Victims


and information needed to bill liability payers.

• Personal Liability Insurance • Business Liability Insurance • Product Liability Insurance • Patient Access and Billing Codes • Why Patient Access and Not Billing • Conditional Payments • Knowledge Check: Billing and Claims Processing

Requirements •

Lesson: At-Fault and No-Fault Auto Insurance

This lesson explains the two primary types of insurance used to cover motor vehicle (MV) accidents—no-fault automobile insurance and at-fault automobile insurance, and describes the key features of each type. It also discusses the challenges involved in registering MV accident victims and offers best practices both for identifying which insurer is responsible for paying for the patient's care, and for collecting the important details about the accident that are required for billing. Coordination of benefits (COB) between multiple payers is also discussed. The purpose of this lesson is to help Patient Access staff understand how pivotal their role is in identifying when a motor vehicle accident is involved in a patient's injury, and the importance of asking the right questions and collecting critical information needed for accurate and compliant billing and payment of the claim.

• Recall information that must be collected during registration for a patient involved in a motor vehicle accident.

• Identify the main characteristics of at-fault and no-fault automobile insurance.

• Recall the requirements about the injury and the motor vehicle that must be met before making a no-fault claim.

• Demonstrate knowledge of how coordination of benefits (COB) works in MV accident cases.

• Identify the MV accident-related occurrence codes that are assigned during the registration process and their impact on billing.

• Impact of Motor Vehicle Accidents on Healthcare • Introduction to Auto Insurance • Responsibility for Payment Varies by State and

Type of Policy • General Guidelines for Assigning the Primary

Payer in MV Accident Cases • Knowledge Check: Auto Insurance Review • Collecting Identification, Demographic, and

Insurance Information • Importance of Collecting Auto Insurance

Information • Best Practices for Collecting MV Accident Injury

Information • Collecting Accident Information from Ambulance

and ED Reports • Scheduled Services for MV Accident Patients • Knowledge Check: Collecting Accident

Information Review • Introduction to At-Fault Insurance • States with Personal Injury Protection Add-On

Policies • Knowledge Check: At-Fault States • Introduction to No-Fault Auto Insurance • List of No-Fault States


• Requirements for Claiming Benefits Under No-Fault

• Who is Covered by No-Fault Insurance Policies • Motorcyclist Coverage • Case Study: Determining Which Insurer to Bill • Knowledge Check: No-Fault • Coordination of Benefits in MV Accident Cases • Selecting the Primary Payer in Various Situations • Subrogation and Conditional Payments • Occurrence Codes • Knowledge Check: Coordination of Benefits

Course: Scheduling and Registration

Lesson: Collection and Verification of Patient Information

This lesson explains the importance of the patient intake process used by Patient Access staff to schedule and register patients. The goal of the process is to:

• Obtain complete and accurate patient-specific identification, demographic, and health insurance information

• Verify the patient's identity and health insurance eligibility before or at the time of hospital admission or an outpatient encounter

This process is vital to providing appropriate patient care, facilitating the timely processing of claims and payments, and ensuring accurate data reporting. The lesson includes information about the master person index (MPI) and coordination of benefits (COB), as well as instructions and

• Recall the steps used to ensure accurate information is collected from patients

• Define master person index (MPI), medical record number, and account number

• Identify which documents help ensure accurate capture of patient demographics

• Identify three ways to verify a patient's health insurance

• Distinguish among insurer verification, benefits, and authorization

• Recognize the importance of collecting all pertinent patient financial information before, or at the time of, services

• Communicate effectively with the patient to obtain needed information

• Introduction to the Patient Intake Process • Importance of Complete and Accurate Collection

and Verification of Patient Information • Be Courteous, Polite, Professional, and Friendly

When Communicating • Knowledge Check: Courteous and Friendly

Communication • Scheduling Process • Registering Emergency Patients • Knowledge Check: Distinguishing Between

Scheduled and Unscheduled Services • Verifying the Patient’s Identify by Phone • Case Scenario: Verifying the Patients Identity by

Phone • Verifying the Patient’s Identity Face-to-Face • Case Study: Verifying the Patient’s Identity Face-

to-Face • Verifying Patient’s Identification Information • Patient Name and Insurance • Knowledge Check: Patient’s Identity


tips on how to communicate effectively with patients to obtain the information needed.

• Master Person Index (MPI) and Pedical Record Number

• Consequence of Misidentifying the Patient in the Master Patient Index

• Registration and Account Numbers • Account Number Example • Knowledge Check: Account Numbers • Collecting and Verifying Patient Demographics • Knowledge Check: Demographic Information • Common Errors Entering or Updating

Demographic Information in the Computer System

• Missing and Incomplete Information • How to Ask Questions and Repeat Back • Example of how to Collect Demographic

Information from a Patient • Knowledge Check: Collecting Accurate

Information from Patients • Verifying Insurance: Collect Copies of Cards and

Information • Insurance Cards • Verifying the Guarantor • Create and Audit Trail: During Registration, Scan

or Copy Documents • Case Scenario: Communicating with the Patient • Knowledge Check: Review of Verification of

Insurance Information • Verifying Insurance Eligibility • Case Example: Insurance Rejected • Verifying Benefits • Verifying In-and Out-of-Network Status • Knowledge Check: Insurance Verification Process • Health Insurance and Coordination of Benefits

(COB)


• Government Payers and COB • Common COB Situations • COB for Children • COB Example • Knowledge Check: Coordination of Benefits • Collection and Verification Process Review

Lesson: Referrals, Preauthorizations, and Precertifications

This lesson explains the purpose and use of referrals and preauthorizations as a means to control costs and ensure that the patient receives only medically necessary care. Emphasis is placed on the Patient Access staff's role in obtaining these documents, and the impact they have on preventing claim rejections and denials. This lesson defines precertification and other terms used to describe the prior approval process. It also describes the steps that Patient Access staff must follow to obtain authorization from the patient's insurer for a service, procedure, or treatment. This lesson also describes the prenotification process that patients and hospitals must use to alert the insurer in the event that patient has an unplanned admission to the hospital.

• Define the terms referral, precertification, and preauthorization.

• Recall the purpose of referrals, preauthorizations, and prenotifications.

• List three possible steps involved in obtaining a referral or preauthorization.

• Recognize alternative terms for preauthorization.

• Identify the consequences when referrals, preauthorizations, and prenotifications are not obtained.

• Referrals • Preauthorization • Examples of when Prior Approval is Required • Prenotification for Inpatient Care • Knowledge Check: Define the Terms • Authorization Matrix or Grid • Authorization Matrix or Grid Examples • Examples of How to Use the Grid • Coverage and Requirements with an Isureer May

Vary by Employer • Knowledge Check: Authorization Matrix of

Outpatient Services • How Referrals are Sent from the PCP to Other

Providers and to the Insurer • Case Scenario: Referrals • Who Obtains the Preauthorization • Patient Responsibility and Notification • Precertification Process • Submitting Preauthorization Requests • What to do if Preauthorization is Missing • Recap of the Steps in the Precertification Process • Case Scenario: Precertification Process • Knowledge Check: The Precertification Process • Urgent and Emergent Services • Case Scenario: Urgent and Emergent Services • Knowledge Check: Prenotification Review


• Process for Handling Situations When Prior Approval was not Obtained

• Case Scenario: Preauthorization not Obtained • Communicating with Patients About Missing

Preauthorizations and Denials • Knowledge Check: Communicating with patients

Lesson: Medicare Secondary Payer (MSP)

This lesson explains the Medicare Secondary Payer (MSP) program. Its purpose is to help Patient Access staff understand the importance of their role in determining the primary payer when a Medicare patient has more than one possible payer. It describes the process that Patient Access staff must follow to make this determination. It also introduces the MSP questionnaire (MSPQ) and provides instructions on how and when to complete it.

• Identify when it is appropriate to complete a Medicare Secondary Payer questionnaire (MSPQ).

• Recall why the MSP program was started.

• List consequences when the MSP process is not correctly followed.

• Sequence the four steps used to determine the primary payer.

• Select the correct primary insurer for common scenarios

• Importance of Identifying and Verifying all the Patient’s Insurers

• Knowledge Check: Review of Terms and Definitions

• Medicare Secondary Payer Program • Legal and Fiscal Responsibility • Determining if the MSP Questionnaire Needs to

be Completed • Case Scenario: Explaining the Purpose of the MSP

Questionnaire • Knowledge Check: MSP Program Review • Verifying Medicare Status • MSP Information in the Common Working File • Patient Responsibility • Example of an MSP Occurrence in the CWF • Knowledge Check: Asking the Right Questions • MSP Questionnaire • Part 1- Covered by Other Government-Sponsored

Programs • Part 2-Non-Work-Related Accident • Part 3-Reason for Having Medicare • Part 4-AGE as the Reason for Qualifying for

Medicare • Part 5-People Who Have Medicare Because of

Disability • Part 6-End Stage Renal Disease (ESRD) • Common Examples When Medicare is Secondary


• Common Examples When Medicare is Primary • Knowledge Check: MSP Questionnaire and

Determining Who is Primary • When Patients Cannot Recall Retirement Date • MSPQ Exceptions • Recurring Outpatient Services and MSP

Information • Knowledge Check: Other MSP Issues • Provider Responsibilities • Knowledge Check: Providers and the MSP

Questionnaire • Tips for Ensuring Accurate Claims Submission and

Prompt Payment

Lesson: Advanced Beneficiary Notice of Noncoverage (ABN)

This lesson explains the following: Purpose and use of the Advance Beneficiary Notice for Noncoverage (ABN) Important role Patient Access staff play in identifying situations that require an ABN Financial consequences if an ABN is not given to the patient when it is required The lesson provides Patient Access staff with instructions for: When an ABN is needed How to complete an ABN How to explain the informaton on the ABN to the patient The lesson describes outpatient hospital services and items that are normally covered by Original Medicare but might not be covered or paid by Medicare in certain situations. The main reasons for

• Recall the meanings of the terms medically necessary, frequency or usage limitations, advance beneficiary notice (ABN), and notifier.

• Identify the purpose of an ABN. • Recognize situations in which an

ABN is needed. • Complete an ABN. • Demonstrate knowledge of how to

explain the information on an ABN to the patient.

• Differentiate between the ABN-related CPT/HCPCS modifiers (GA, GX, GY, and GZ).

• Introduction to the ABN • Purpose of ABNs • Knowledge Check: Billing Outpatient Visit Types • When an ABN is Needed or Recommended • Lack of Medicare Necessity • Frequency or Usage Limits • Capped Therapy Services • Knowledge Check: ABN Situations • Services that are Never Covered • Prohibited ABNs • Repetitive Services ABNs • Knowledge Check: Restricted or Prohibited ABNs • ABN General Requirements • ABN Notifiers • ABN Delivery Requirements • Case Study: Delivery of an ABN • The ABN Form • The Header of the Form: Sections A-C • Section #: Description of Item(s) • Completing Section D Examples


noncoverage presented in this lesson are services or items that are determined to be not medically necessary or situations in which the patient has exceeded frequency (or usage) limitations. Situations in which an ABN is not required but highly recommended because the service is never covered, such as cosmetic surgery and experimental treatments, are also discussed. The lesson includes information on the definitions and use of the CPT/HCPCS modifiers that are associated with ABNs—specifically, GA, GX, GY, and GZ. The importance of recognizing situations where these modifiers are needed, and making sure the billing staff is alerted so that they are entered on the claim, is emphasized.

• Section E: Reason(s) Medicare May Not Pay • Use of Software to Determine Reason Medicare

May Not Pay • Section F: Estimated Cost • Section G: Options • Section H: Additional Information • Sections I&J: Signatures and Date • Case Study: ABN Example • Case Study: Practice Completing an ABN • Purpose of ABN Modifier • ABN Modifier Descriptions • Knowledge Check: Use of ABN Modifiers •

Lesson: Medicare Necessity

This lesson provides an overview of the concept of medical necessity as it relates to Medicare paying (or not paying) for services. It explains how Medicare compares the diagnostic and procedural information reported on the UB-04 hospital claim or on the CMS-1500 claim form to criteria published by the Centers for Medicare and Medicaid Services (CMS) in its National Coverage Determinations (NCDs) and the Medicare administrative contractors' (MACs) Local Coverage Determinations (LCDs) to determine if an item or service meets CMS standards for medical necessity.

• Define medical necessity. • Identify the two key elements that

establish medically necessary. • Distinguish between NCDs and

LCDs. • Access NCDs and LCDs. • Apply commonly used NCDs and

LCDs.

• Medical Necessity Criteria • Medical Necessity Documentation • Inpatient Medical Necessity • Negative Consequences of Providing Care That is

Not Medically Necessary • Examples of Negative Consequences • Knowledge Check: Compliance and Understanding

Medical Necessity Definitions • Role of Patient Access in Verifying Medical

Necessity of Care • Medical Necessity Verification • Knowledge Check: Determining Medical Necessity • Medicare’s Coverage Policy • Staff Responsible for Checking NCDs • NCD Development and Publication


The purpose of this lesson is to enable Patient Access staff and others involved in the revenue cycle process to make accurate determinations about medical necessity and the likelihood that Medicare will pay (or not pay) for common outpatient services.

• Example NCDs for Computer Tomography (CT) Scans

• Local Coverage Determinations (LCDs) • Knowledge Check: Medical Necessity-NCDs and

LCDs • Impact of Rejected Laboratory Tests • Clinical Diagnostic Laboratory Services Included in

the NCD Lab Manual • Laboratory Test Orders • Reason for Lab Tests – Diagnosis or Signs and

Symptoms • Example: Lab NCD for Prothrombin Time • Example: Checking lab Test Orders for Medical

Necessity • Knowledge Check: Lab Orders • To Determine Medical Necessity

Lesson: HIPAA Privacy and Patient Acknowledgements

This lesson provides an overview of the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, including details specific to providing the patient with the facility's privacy notification and the patient's acknowledgement of it. The lesson lists the patient's information privacy rights and defines protected health information (PHI). It explains how and how not to share and process PHI, and how Patient Access staff should handle PHI to ensure patient privacy and confidentiality. In addition, it discusses the consequences of noncompliance.

• Identify information protected under the HIPAA privacy laws.

• Define PHI. • Recognize the consequences of

noncompliance under the HIPAA privacy law.

• Recall when the acknowledgement of the Privacy Notice is given, and where and how it must be displayed.

• Specify when PHI may be disclosed.

• HIPAA Privacy and Patient Acknowledgements • Laws that Protect Patient Privacy • Patient Information Privacy Rights • Knowledge Check: Introduction to HIPAA and

ARRA • Definition of PHI • Situations in which PHI can be Shared Without the

Patient’s Specific Authorization • Types of Protected Health Information • Knowledge Check: Review of PHI Types • Types of Privacy Breaches • Healthcare Data and Privacy Breaches: Press

Releases • Consequences of HIPAA Violations • Criminal Charges • Bottom Line


• HIPAA Practice Scenarios • Think Before You Act • Knowledge Check: Consequences of HIPAA

Violations • Notice of Privacy Practices for Protected Health

Information • Deliver of the Notice and Acknowledgement • Additional Questions and Consents • Communicating with a Patient and Family,

Friends, or Caregivers • Case Scenario: Obtaining Consent and

Acknowledgement of Privacy Notice Form • Availability of the Privacy Notice • Case Study: Privacy Notice Distribution • Patient Directory Authorization • Patient Directories: Case Scenario • Patient Directory Authorizations in Emergency

Situations • Death and PHI • Additional Privacy Concerns and

Recommendations • Knowledge Check: Privacy Practices

Lesson: Preventing Claim Rejections and Denials

This lesson provides information and best practices aimed at preventing errors from occurring during the collection and verification of medical, demographic, and insurance information. To help Patient Access staff understand the importance of their role in reducing the number of rejected or denied claims, this lesson explains the impact that scheduling and registration errors can have on the

• Define and recognize a claim rejection or denial.

• List at least three processes Patient Access staff control that affect the number of rejections and denials.

• Identify different types of common mistakes made by Patient Access staff that cause rejections and denials.

• Cite how quickly claims may be paid.

• Impact of Denials • Best Practice: Payment in 14 Days or Less • Knowledge Check: Claim Denials and Best Practice

Overview • Defining Rejections and Denials • Administrative, Technical, or Operational

Rejections and Denials • Clinical Denials • Not Documenting Medical Necessity • Knowledge Check: Rejections and Denials • Errors Involving Patient Names


organization's finances. It also defines key terms, such as Remittance Advice (RA), Claim Adjustment Reason Codes (CARC), and Remittance Advice Remark Codes (RARC) that Patient Access staff and administration analyze to determine reasons for denials and rejections, evaluate impact, and make improvements.

• Differentiate between the 270/271 insurance verification transaction, Claim Adjustment Reason Codes, and Remittance Advice Remark Codes.

• Recall the real and potential consequences when claims are returned, rejected, or denied.

• Errors Involving the Spelling of Patient’s names • Errors Involving Nicknames, Name Derivatives,

and use of Initials • Best Practice: Preventing Errors in Patients’

Names • Case Scenario: Incorrect Spelling of Patient’s

Name • Knowledge Check: Recognizing Errors in Names • Typographical Errors with Numbers and Dates • Errors Involving Insurance ID Numbers • Best Practice for Verifying Numbers and Dates are

Accurate • Knowledge Check: Errors Entering Patient

Insurance Identification Numbers • Medicare Cards: Current and New Format • Ensure Correct Medicare Identification Numbers:

Current Card • Understanding the Medicare HICN Suffix on the

Current Card • Railroad Retiree Numbers • Ensure Correct Medicare Identification Numbers:

New Card • Failure to Check for Medicare Part B Coverage • Knowledge Check: Case Study Scenario: Failure to

Notice That Patient Does Not Have Medicare Part B

• Knowledge Check: Patient’s Medicare Information Incorrect on the Claim

• Other Reasons for Medicare Claims Denials • Medicare Claim Rejection and Denial Categories • Return to Provider • Rejected Claims • Denied Claims


• Best Practice to Avoid Medicare Claim Rejections and Denials

• Knowledge Check: Case Study: Reasons for Medicare Claim Rejections and Denials

• Types of Rejection and Denial Codes • Claim Adjustment Reason Codes (CARC) • Remittance Advice Remark Codes (RARC) • Group Codes • Case Scenario: CARC 6- Service not Consistent

with Patient’s Age • Errors Made by Insurers • Impact of Denials and Rejections • Case Study: Impact of Denials and Rejections • Knowledge Check: Case Scenario Review • Patient Access” Role in Preventing Rejections and

Denials • Summary of Best Practice Tips for Preventing

Errors

Lesson: Point-of-Service Collections

This lesson provides information on:

• Best practices for educating patients about insurance coverage

• How to help patients understand their financial responsibility

• Guidance on how to collect the patient's portion of payment before or at the time of service, also known as point-of-service (POS) collections

Examples of communication scripts are included, as well as suggested policies that will help staff to be successful with POS collections.

• This lesson provides information on:

• Best practices for educating patients about insurance coverage

• How to help patients understand their financial responsibility

• Guidance on how to collect the patient's portion of payment before or at the time of service, also known as point-of-service (POS) collections

• Examples of communication scripts are included, as well as suggested policies that will help staff to be successful with POS collections.

• The Insurance Landscape • Defining Consumerism • Comparing Performance and Cost • Hospital Compare Information • Charges and Pricing • Uninsured • Knowledge Check: Consumerism Review • Workflow • Fundamentals for POS Collection • POS Definitions • Knowledge Check: Determining Patient

Responsibility • Knowledge Check: Fundamentals of POS • EMTALA


• Regulation for Not-for-Profit Hospitals: IRC Section 501(r)

• Knowledge Check: Regulations • Introduction to Policies and Procedures • Policy and Procedure Approval and Maintenance • Financial Assistance Policy (FAP) • Point-of-Service Collection (POS) Policy • Payment Plan Policies • Estimating Cost-Share • Estimating Examples • Knowledge Check: Point-of-Service Collection

Policy • Knowledge Check: Policy and Procedure Terms • Implementing POS Collections • Key Steps for Phone Collection • Preregistration Case Scenario: Setting a Payment

Plan • Preregistration Case Scenario: Handling an Irate

Patient • Knowledge Check: Discussing POS Payment with a

Patient

Course: Designating Patient Service Type (Account Class)

Lesson: An Overview and Impact of Patient Service Type

This lesson emphasizes the important role that the Patient Access staff has in selecting the correct patient type for each patient. It explains how the patient type is determined from the information and instructions in the physician's order, or by the reason and location where the patient seeks care, such as the hospital's emergency department (ED). It also describes the role the patient type designation has in the accomplishment of the following functions:

• This lesson emphasizes the important role that the Patient Access staff has in selecting the correct patient type for each patient. It explains how the patient type is determined from the information and instructions in the physician's order, or by the reason and location where the patient seeks care, such as the hospital's emergency department (ED). It also

• Understanding Patient Type Classifications Within Your Facility

• Patient Type Terminology • Patient Type Codes • Knowledge Check: Patient Type Code

Characteristics • Physician Orders • Scheduling Services • Need for Referrals, Precertification, and Prior

Authorization of Services • Other Patient Type Insurer Requirements


• Providing correct services to the patient in a smooth and efficient manner

• Meeting insurer requirements for coverage and payment

• Ensuring that the charging and billing of services is done correctly

• Categorizing the patient for tracking and management purposes

The lesson also points out the consequences that the incorrect selection of patient type can have on the patient, the physician (or other care provider), and the hospital.

describes the role the patient type designation has in the accomplishment of the following functions:

• Providing correct services to the patient in a smooth and efficient manner

• Meeting insurer requirements for coverage and payment

• Ensuring that the charging and billing of services is done correctly

• Categorizing the patient for tracking and management purposes

• The lesson also points out the consequences that the incorrect selection of patient type can have on the patient, the physician (or other care provider), and the hospital.

• Knowledge Check: Ordering and Scheduling Services

• Authorization Matrix Example for Outpatient Services

• Knowledge Check: Authorization Matrix of Outpatient Services

• Importance of Correct Patient Type • Patient Types’ Impact on Charging and Billing • Inpatient Billing and Payment • Inpatient Billing and Payment Methods • Knowledge Check: Billing Review • Budget, Finance, and Statistics • Case Study: Incorrect Patient Type Impact on

Hospital Payments

Lesson: Scheduled Outpatient Visits

This lesson describes patient types for scheduled outpatient visits provided in a physician's office or clinic.

• It reviews the different requirements of provider-based departments (PBDs) versus the free-standing clinics, as well as community health centers.

• It defines new and established patient types and the necessity of Patient Access staff understanding the difference in these patient types

• This lesson describes patient types for scheduled outpatient visits provided in a physician's office or clinic.

• It reviews the different requirements of provider-based departments (PBDs) versus the free-standing clinics, as well as community health centers.

• It defines new and established patient types and the necessity of Patient Access staff understanding the difference in these patient

• Scheduled Outpatient Visit Settings • Knowledge Check: Review of Scheduled

Outpatient Visit Settings • Scheduled Medical Care Visits • Outpatient Provider-Based Department or Clinic

Visits • Knowledge Check: Reasons for Scheduled

Outpatient Visits • Hospital Outpatient Billing for Scheduled Visits • Case Study: Hospital-Based Departments or

Clinics • Knowledge Check: Billing Outpatient Visit Types


when it comes to scheduling and billing the patient's visit.

types when it comes to scheduling and billing the patient's visit.

• Impact of Patient Type of Scheduling New and Established patients

• Definition of “New” Versus “Established” Patients • Case Scenario: Scheduling Patients • Knowledge Check: Distinguishing Between New

and Established Patients

Lesson: Scheduled Hospital Outpatient Services

This lesson provides an introduction to scheduled outpatient services patient types. It examines the most common hospital outpatient patient types, including the following:

• Ambulatory surgery • Endoscopic services, including

colonoscopy and bronchoscopy • Diagnostic tests • Chemotherapy and radiation

treatments • Rehabilitative, physical,

speech/language, occupational, and respiratory therapy

• Dialysis It covers the information that Patient Access requires from the ordering physician to properly select the patient type for the planned test, procedure, or therapy, including services that are provided on weekly or monthly schedules, such as physical therapy or dialysis.

• This lesson provides an introduction to scheduled outpatient services patient types. It examines the most common hospital outpatient patient types, including the following:

• Ambulatory surgery • Endoscopic services, including

colonoscopy and bronchoscopy • Diagnostic tests • Chemotherapy and radiation

treatments • Rehabilitative, physical,

speech/language, occupational, and respiratory therapy

• Dialysis • It covers the information that

Patient Access requires from the ordering physician to properly select the patient type for the planned test, procedure, or therapy, including services that are provided on weekly or monthly schedules, such as physical therapy or dialysis.

•

• Overview of Scheduled Outpatient Services • Ambulatory Surgery Patient Types • Inpatient Only Procedure List • Diagnostic medical Tests and Services • Endoscopic Procedures Services • Endoscopy Surgical Suites • Knowledge Check: Differentiating Between

Diagnostic Services Patient Types • Chemotherapy, Radiation, and Intravenous

Therapy • Chemotherapy • Radiation Therapy • Intravenous Therapy • Knowledge Check: Chemotherapy, Radiation

Therapy, Intravenous Therapy Review • Rehabilitative Therapy • Physical Therapy • Occupational Therapy • Speech and Language Therapy • Respiratory Therapy • Knowledge Check: Rehabilitative Services Patient

Types Review • Dialysis for End-Stage Renal Disease (ESRD) • Knowledge Check: Differentiating Dialysis

Treatments •

Lesson: Unscheduled Hospital Outpatient Visits


This lesson introduces patient types for unscheduled outpatient services provided in a hospital setting. It examines patient types for urgent care, emergency departments (EDs), trauma centers, and observation care. Although some hospitals allow other types of unscheduled services, such as simple x-rays and lab services, this lesson will not focus on those services.

• Identify specific unscheduled outpatient patient types.

• Specify the types of services that are typically provided in an urgent care center.

• List the key differences between Type A and Type B emergency departments.

• Differentiate between emergency department and observation care patient types.

• Identify the Medicare Outpatient Observation Notice (MOON) form and when it is appropriate to give it to Medicare and Medicare Advantage patients.

• Overview of Unscheduled Hospital Outpatient Services

• Overview of Other Types of Unscheduled Hospital Outpatient Services

• Scope of Urgent Services and Locations • Knowledge Check: Urgent Care Conditions • Overview of Emergency Department Services • Emergency medical Treatment and Active Labor

Act (EMTALA) • Emergency Departments: Type A and Type B • Fast-Track EDs • Emergency Department Workflow • Hospitals with More than One Emergency

Department • CPT/HCPCS for Emergency Departments • Knowledge Check: Review of Emergency

Department Types • Emergency Department Outpatient Services

Treatment • EDs Designated as Trauma Centers • Observation Patients • Physician Orders for Observation Care • Where Observation Services are Rendered • Knowledge Check: Understanding Observation

Services • Case Study: Observation Care

Lesson: Inpatient Types for Distinct Hospital Units

This lesson introduces several patient types and service locations used to identify patients admitted to a hospital or one of its special care or distinct part units.

• It defines inpatient care and describes different types of hospitals.

• Recall different types of hospitals. • Identify the characteristics of a

patient who meets the inpatient definition.

• Distinguish between scheduled and unscheduled admissions.

• Acute-Care Hospitals • Characteristics of Acute-Care Hospitals • Hospital Designations: Teaching Versus

Nonteaching • Hospital Designations: Critical-Access Hospitals

(CAHs) • Hospital Designations: Other Types


• It explains the difference between scheduled and unscheduled inpatient admissions, and outpatients who are converted to inpatients under the 2-midnight rule.

This information is important to helping Patient Access staff correctly identify which patient type and service location are appropriate for a specific inpatient.

• Recognize the patient type/service location associated with each type of hospital care unit.

• Define a distinct part unit. • Demonstrate knowledge of the 2-

midnight rule and inpatient-only procedures.

• Knowledge Check: Hospital Types • Inpatient Acute Care • Unscheduled and Scheduled Admissions • Knowledge Check: Common Reasons for

Unscheduled and Scheduled Inpatient Admission • 2-Midnight Rule • Case Example: 2-Midnight Rule • Changing Patient Type Because of the 2-Midnight

Rule • Knowledge Check: 2-Midnight Rule Requirements • Admission Orders • Admission to a Particular Unit or Bed Type • Case Scenario: Inpatient Type • Inpatient Surgical patient Types • Inpatient Only Procedures • Knowledge Check: Inpatient Surgical Patient

Types • Special Care Units • Inpatient Hospice, Palliative, and/or Respite Care

Patient Types • Knowledge Check: Special Inpatient Patient Types • Distinct part Hospital Inpatient Unit • Impact of Care and Payment • Inpatient Psychiatric Facility (IPF) Distinct Unit • Case Scenario: patient Transferred from Acute-

Care to IPF • Inpatient Rehabilitation Facilities (IRFs) • Case Scenario: Patient Transferred and

Discharged to an IRF • Skilled Nursing Facility (SNF) and Swing Beds • Knowledge Check: Identify Distinct Part Units • Determining the Patient’s Unit and Type • Knowledge Check: Selecting Correct patient

Types/Hospital Units


• Patient Type and Bed Charges

Lesson: Obstetrics, Newborn, and Pediatric Patient Types

This lesson provides information relating to patient types for obstetrical care, newborn care, and pediatric care.

• The lesson covers inpatient, outpatient, and clinic care for obstetrical patient types and provides examples of when the different types of care are provided.

• It explains inpatient newborn patient types and deals with hospital care and the registering of a newborn baby.

• The pediatric care type covered in this lesson focuses on both outpatient and inpatient care types, and how it is typically afforded to all babies (except newborns) and children through the age of 19.

• This lesson provides information relating to patient types for obstetrical care, newborn care, and pediatric care.

• The lesson covers inpatient, outpatient, and clinic care for obstetrical patient types and provides examples of when the different types of care are provided.

• It explains inpatient newborn patient types and deals with hospital care and the registering of a newborn baby.

• The pediatric care type covered in this lesson focuses on both outpatient and inpatient care types, and how it is typically afforded to all babies (except newborns) and children through the age of 19.

• Overview of Obstetrical Care Patient Types • Obstetrical Care Settings • Scheduled Outpatient Obstetrics Visit patient

Types • Unscheduled Outpatient Obstetrics Services

Patient Types • Definitions of Threatened Abortion, Miscarriage,

Preterm Labor, and False Labor • Processes Used to Care for Pregnant Women

Having Contractions • Unscheduled Care Types for Conditions that May

or May Not Be Related to the Pregnancy • Knowledge Check: Obstetrical Care Types • Inpatient Obstetrical Care Types • Knowledge Check: Newborn patient Types

Registration and Naming Conventions • Inpatient Care: The Newborn Infant • Case Study: Newborns and Nursery Levels • Newborn Registration and Medical Record

Number • Newborn Naming Conventions • Updating Records to Include Newborns’ Legal

Names • Knowledge Check: Newborn patient Types

Registration and Naming Conventions • Pediatric Care • Scheduled and Unscheduled Outpatient Care • Inpatient Pediatric Care Types • Knowledge Check: Pediatric Care Type Review •

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