Program Brief

Claims Settlement of the Cooperative Health Insurance is one of the most important risk management and customer acquisition tools in the insurance sector. The program is designed to provide participants with the knowledge and skills to undertake the health insurance claims handling process including notification, assessment, settlement, financial factors, and associated legal background. It also reviews and estimates claims reserves, including Outstanding Reserves and IBNR.

Program Goals

At the end of the training program, the participant should be able to:

  • Recognize the role of the health insurance claims department in the operations of insurance companies to maintain the profitability of companies.
  • Understand the health insurance claims operations cycle of data collection and analysis, handling claims and investigating claims to ensure that quality requirements are met.
  • Understanding of the regulations and procedures to ensure the identification of suspicious claims fraudulent for health insurance claims and identification of cases of claims Leakage.
  • The ability to manage relationships with stakeholders using the best negotiating practices relating to files and claims cases.
  • Identify how to Create a claim reserve, calculate the loss ratio and the role of reinsurance to control of catastrophic health insurance claims.
Program Agenda
Module 1: Cooperative Health Insurance Policy
  • 1 Definitions, Limitations, and Exclusions

    • 2 General Conditions

      • 3 Schedule of Benefit (SOB), and Appendixes

        • 4 Unified Medical Declaration Form

          • 5 Recoverable Expenses/ Benefits

            Module 2: Claims Settlement Principles of the Cooperative Health Insurance
            • 1 Legal Requirements of Claim Notification

              • 2 Policy Requirements of Claims

                • 3 Settling Claims based on Policy Condition

                  • 4 Duties of the insured when a Claim/Loss is incurred

                    • 5 Duties of medical services providers in medical insurance claims

                      • 6 Claim Supporting Documents

                        Module 3: Settlement Procedure
                        • 1 Eligibility

                          • 2 Prior Authorization

                            • 3 Deductibles

                              • 4 Coinsurance

                                • 5 Copayment

                                  • 6 Documentation

                                    • 7 Electronic Claim

                                      • 8 Medical Fraud

                                        • 9 Invalid Claim

                                          • 10 Partially Fulfilled Settlement

                                            • 11 Final Review

                                              • 12 Payment (Remittance)

                                                • 13 Other Methods of Settlement

                                                  Module 4: Health Insurance Claims Department Role
                                                  • 1 Organizational Structure

                                                    • 2 Responsibilities of Claim Staff

                                                      • 3 Customer Service Standards: Fair Treatment and Managing Expectations

                                                        • 4 Claim Estimation

                                                          • 5 Reserve Allocation

                                                            • 6 Laws and Regulations

                                                              Module 5: Cost Control
                                                              • 1 Expense Management

                                                                • Roles of the Claims Manager

                                                                  • Control of Operational Costs

                                                                    • Promoting Economically Effective Medical Care Services

                                                                      • Cost Sharing

                                                                        • Recover Claim Payments from a Third Party

                                                                          • Incentives for Cost-Effective Alternatives

                                                                            • Patient Referral Leakage/ Network Leakage: How to identify and reduce?

                                                                              • Types of Financial Control and their effect on the insurance company’s results

                                                                              • 2 (Claim Management Software Solutions (Systems

                                                                                • 3 Claims Management Company (Third Party Administrator)

                                                                                  Program Requirements

                                                                                  Not Available

                                                                                  Program Path

                                                                                  Names of the training programs that are integrated (enriched) with the training program:

                                                                                  • Not Available

                                                                                  Names of the training programs that after the training program:

                                                                                  • Not Available
                                                                                  Program Method
                                                                                  • Other
                                                                                  • Lecture
                                                                                  • Practical Implementation
                                                                                  • Exercises and assignments
                                                                                  Evaluation Method
                                                                                  • Pre Exam
                                                                                  • Post Exam
                                                                                  Training Type
                                                                                  • In Class Training
                                                                                  • Online Training
                                                                                  Partners

                                                                                  Not Available

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