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Master the settlement of Cooperative Health Insurance claims — a pivotal tool in risk management and customer retention. This program will equip you with the knowledge and skills needed to efficiently handle claims, with a clear understanding of financial factors and the legal framework. You will also learn how to estimate various types of claim reserves.
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.
Insurance
+5
Operations
Not Exist
Other
Lecture +2
Other
Lecture
Practical Implementation
Exercises and assignments
Pre Exam
Post Exam
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This provides you with the opportunity to select the available times that suit you best for participation in our program. These times represent slots during which we are ready to welcome you and provide assistance and guidance.
In Class Training-Online Training
Definitions, Limitations, and Exclusions
General Conditions
Schedule of Benefit (SOB), and Appendixes
Unified Medical Declaration Form
Recoverable Expenses/ Benefits
In Class Training-Online Training
Legal Requirements of Claim Notification
Policy Requirements of Claims
Settling Claims based on Policy Condition
Duties of the insured when a Claim/Loss is incurred
Duties of medical services providers in medical insurance claims
Claim Supporting Documents
In Class Training-Online Training
Eligibility
Prior Authorization
Deductibles
Coinsurance
Copayment
Documentation
Electronic Claim
Medical Fraud
Invalid Claim
Partially Fulfilled Settlement
Final Review
Payment (Remittance)
Other Methods of Settlement
In Class Training-Online Training
Organizational Structure
Responsibilities of Claim Staff
Customer Service Standards: Fair Treatment and Managing Expectations
Claim Estimation
Reserve Allocation
Laws and Regulations
In Class Training-Online Training
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
(Claim Management Software Solutions (Systems
Claims Management Company (Third Party Administrator)
Recognize the role of the health insurance claims department in the operations of insurance companies to maintain the profitability of companies.
Understanding the health insurance claims process cycle, including data collection, analysis, claim handling, and investigation—ensuring the fulfillment of quality requirements.
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.
