Description

Course Name: Certificate in Medical Insurance Claims Management

Global Occupational Skill Standard – GOSS ID: GOSS/HF/CMICM/V1

Eligibility: 10+2 (Higher Secondary) or Equivalent.

Duration: Three Months.

Objective: The Certificate in Medical Insurance Claims Management course aims to develop comprehensive knowledge and practical skills required to accurately process, review, and manage health insurance claims. The course provides in-depth understanding of health insurance principles, policy structures, coding systems, regulatory requirements, and claims adjudication procedures.

Get ready to join the Journey to become a GSDCI Certified Professional  – International Certification and Assessment Body.

Steps to become a GSDCI Certified Professional:

Step 1: Select your certification you want to pursue.

Step 2: Click on get certified tab, new pop up window will open.

Step 3: Click on pay certification fee, you will be redirected to billing details page.

Step 4: Fill your details and click on pay certification fee, you will be redirected to payment gateway, pay fee by any available options like Card (Debit/Credit), Wallet, Paytm, Net banking, UPI and Google pay.

Step 5: You will get Login Credentials of Online E-Books and Online assessment link on your email id, within 48 hrs of payment.

Step 6: After completion of the online assessment, the soft copy of your certificate will be sent to your registered email ID within 5 days.

Assessment Modules:

Module 1: Foundations of Health Insurance and Healthcare Systems: Overview of healthcare delivery systems, Structure and types of health insurance programs, Key terminology used in health insurance and claims, Roles and responsibilities of a Health Insurance Claims Associate, Policyholder and insurer relationships, Regulatory bodies and industry standards

Module 2: Health Insurance Policies, Coverage, and Benefits: Policy components and contract language, Eligibility determination and verification, Covered vs. non-covered services, Preauthorization and referral requirements, Coordination of benefits and dual coverage rules, Understanding deductibles, copays, and coinsurance

Module 3: Medical Coding and Documentation for Claims Processing: Introduction to ICD-10-CM diagnosis coding, Basics of CPT and HCPCS procedure coding, Use of modifiers in billing, Medical documentation requirements, Linking codes to medical necessity, Identifying common coding and documentation errors

Module 4: Claims Processing and Adjudication Workflow: Types of healthcare claims (professional, institutional, pharmacy), Claim form components (CMS-1500 and UB-04), Electronic claims submission standards, Steps in claim adjudication and payment calculation, Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA), Timely filing limits and correction processes

Module 5: Denials, Appeals, and Claims Resolution: Common claim denials and their root causes, Denial management strategies, Writing effective appeal letters, Reconsideration and dispute resolution processes, Audits and claim review procedures, Communication with providers and policyholders

Module 6: Compliance, Ethics, and Regulatory Requirements in Claims Handling: HIPAA privacy and security regulations, Fraud, waste, and abuse prevention, CMS, NAIC, and state regulatory guidelines, Ethical standards in claims decision-making, Data accuracy and record retention requirements, Continuous learning and professional conduct

GSDCI Online Assessment Detail:

• Duration- 60 minutes.
• Number of Questions- 30.
• Number of Questions from each module: 5.
• Language: English.
• Exam Type: Multiple Choice Questions.
• Maximum Marks- 100, Passing Marks- 50%.
• There is no negative marking in any module.

Benefits of Certification:

1. Global Recognition & Credibility – Stand out worldwide with a certification that strengthens your professional profile across borders and demonstrates your skills to employers and institutions.

2. Quality Assurance through ISO Certification – Programs follow an ISO-certified quality management system to promote consistency, reliability, and a standardized learning experience.

3. Career Advancement & Employability – Enhance your résumé, demonstrate professional competence, and improve your prospects for career growth, promotions, or suitable job opportunities.

4. Non-Profit Trust Factor – Certification from a non-profit organization reflects a mission-driven approach focused on skill development, professional learning, and public benefit.

5. Access to Learning Resources – Gain access to useful learning resources such as e-books, mock tests, assessments, and online academic support.

6. Transparency & Online Verification – Each certification includes a unique enrolment or certificate ID, enabling convenient online verification by employers and other interested parties.

7. Lifetime or Long-Term Validity – Certifications may offer lifetime or extended validity, reducing the need for frequent renewal, subject to the applicable certification scheme.