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.
At the end of the training program, the participant should be able to:
1 Definitions, Limitations, and Exclusions
2 General Conditions
3 Schedule of Benefit (SOB), and Appendixes
4 Unified Medical Declaration Form
5 Recoverable Expenses/ Benefits
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
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
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
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)
Not Available
Names of the training programs that are integrated (enriched) with the training program:
Names of the training programs that after the training program:
Not Available
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