Medical Insurance Verification & Claims Processing Training Course

Course Overview

Learning Objectives

• Apply systematic procedures for verifying medical insurance eligibility and coverage.
• Interpret insurance benefits, exclusions, deductibles, co-payments, and coverage limits.
• Identify referral, pre-authorisation, and medical necessity requirements before service delivery.
• Review patient and clinical documentation for completeness and consistency.
• Prepare and submit accurate medical insurance claims in accordance with payer requirements.
• Understand the relationship between diagnosis coding, procedure coding, and claim reimbursement.
• Identify common causes of claim rejection, denial, and underpayment.
• Apply effective procedures for denial investigation, appeals, correction, and resubmission.
• Reconcile insurance remittance information and outstanding claim balances.
• Use performance indicators to improve claims accuracy, processing efficiency, and reimbursement outcomes.

Who Should Attend

Learning Outcomes

• Verify patient insurance eligibility, policy validity, and coverage limits.
• Explain benefit structures, exclusions, patient financial responsibilities, and payer conditions.
• Determine when referrals, pre-authorisations, or additional clinical documentation are required.
• Validate claim information against patient records, clinical documentation, and payer rules.
• Identify common errors in claim forms, coding, supporting documents, and submission procedures.
• Track claims throughout the adjudication and reimbursement cycle.
• Analyse rejection and denial codes and determine appropriate corrective actions.
• Prepare claim corrections, resubmissions, and appeals using supporting evidence.
• Reconcile remittance advice, payments, adjustments, and outstanding balances.
• Monitor claims performance using indicators such as denial rates, turnaround time, and first-pass acceptance rates.

Course Outline