Essay Example - Medical Coding II

Published: 2023-03-22
Essay Example - Medical Coding II
Type of paper:  Essay
Categories:  Medicine Money Healthcare policy Customer service
Pages: 5
Wordcount: 1173 words
10 min read

Tricare is a health insurance plan that covers the active-duty members, their beneficiaries, retirees, and their family members. Beneficiaries of the Tricare must be registered in the Defense Enrolment Eligibility Reporting System (DEERS). Health insurance benefits comprise various statements delivered to the health care providers to ensure that the insured attains the benefits needed. However, there are cases of reimbursement and refunds that must be considered. The paper examines the elements of Tricare billing, Electronic Remittance Advice forms, reimbursement aspects and workers' compensation.

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Components of TRICARE billing and Benefits Accessible to Active Duty Members, Veterans, and their Family Members

Tricare is a health insurance plan benefitting military members, retirees, and their families. Some of the components of Tricare include Tricare for active duty and dependents; Tricare for reservists, guard members, and their dependents; Tricare for overseas members; Vision plans; Dental plans; Transitional health benefits for recently divorced members; Retiree Tricare; and Tricare for children between 18 and 26 years (Williamson, 2011).

Active duty service members and their beneficiaries (spouses and children enrolled in DEERS) can benefit from Tricare. Active duty members benefit from Tricare Prime, Tricare Prime Remote, Tricare Prime Overseas, and Tricare Prime Remote Overseas. Tricare Prime provides limited out-of-pocket expenses than Tricare Select although there is limited liberty of choice for providers. Tricare Prime Remote offers healthcare insurance using civilian providers for active-duty members. The benefits for veterans rely on income, service linkage, and discharge. Some of the benefits include ancillary services, chiropractic care, eye tests, bereavement counseling, home health care, medical care, maternity and obstetric services, transportation service, mental health, and substance abuse (Williamson, 2011). Tricare also provides other plans to include active-duty families and provides Preferred Provider Organization (PPO) programs for services using civilian providers. Family members of active-duty members also pay limited out-of-pocket expenses, no registration fees, no connection co-payments, and no point-of-service fees.

Significance Attributed to the Electronic Advice Forms

The Electronic Remittance Advance (ERA) is an electronic transaction that offers claim payment data. The forms are utilized by facilities, practices, and billing firms to auto-post claim payments into their frameworks. The significance of the benefits is essential in comprehending how to eradicate manual keys to save time and effort. It also helps in reducing posting mistakes and increasing efficiency and saving finances (Jonson & Linker, 2015). Possessing insight into the details of the insurance plan coverage benefits and having the capability to reconcile the charges and diagnoses delivered on the claim especially when they go against the ERA promote financial well-being in the providers' department.

The elucidation of benefits and the remittance advice forms are essential in comprehending the recipient and content. It is important to distinguish the recipient of the statements. Both kinds of statements offer an illustration of benefits, although the remittance advice is given directly to the healthcare provider while the clarification of the benefits statement is delivered to the insured patient. The details of the explanation of benefits and remittance advice forms differ slightly. Both statements comprise data concerning the patient, any changes in the claims, and the service providers. They also help in understanding the nature of the process followed, the time frame, and the charges.

Reimbursement Follow-up, Appeal Process, and Refund Guidelines

In the billing domain, it is important to understand the reimbursement comprises follow-up. To have an optimum reimbursement claim, it is essential to monitor them until they are compensated. In case there is denial, an assessment for the reason and verdict of the next step is given accordingly. In some situations, a follow-up call to the provider is the most important especially when an appeal is deemed essential (Johnson & Linker, 2015). It is important to ensure that before a verdict on seeking an appeal, clinical records are evaluated for suitable documentation to ensure that there is justification for the claim.

The appeal process follows various steps and it is crucial for the medical office professional to be aware of the prompt documentation of the appeals and precise payer agreements established to monitor the stages suitable for the appeal. Ascertaining whether the rejection is of the aggregate charge is also an essential aspect that should be considered (Johnson & Linker, 2015). Grounded on the aspects of the rejection situation, the appeal process is either addressed as a formal appeal in writing or by phone call.

The issue of a refund is also essential to ensure that no overpayments are made during the process. After the verification that a refund is viable, it is important to ensure financial balance to avoid a mistake. The patient's accounts are adjusted while the reimbursement insurance companies wait for the outcome of the insurance company regarding the refund.

History of Worker's Compensation and Differentiation of Federal Worker's Compensation with State Worker's Compensation

Before the initiation of worker's compensation at the start of the 20th century, the civil courts were responsible for settling disputes in regard to employment-linked damages, diseases, and deaths. The courts had a mandate of ordering employers to offer compensation to injured employees or the survivors of employees who died where it was ruled that the employee showed negligence. The establishment of worker's compensation was propelled by an agreement among employers, employees, and insurers who had supported the implementation of the grand bargain (Guyton, 1999). In employers' perspective, workers' compensation decreased the risks linked to the tort system, which in spite of the benefits in common law, still left the employer liable for eventual expenses in case of an employee injury when determined by a court.

There exists a wide range of differences between federal workers' compensation and state workers' compensation. For injured state employees, workers' compensation costs are paid using the state's workers' compensation act. Some state acts stipulate that there should be short-term aggregate disability benefits, specific loss advantages, death advantages, and short-term partial disability compensations. Contrary, the federal workers' compensation stipulates that when an injury occurs to workers, the Federal Employees Compensation Act must be followed. However, the federal government and its multiple agencies have immunity from public employer liability (Guyton, 1999). This shows that federal workers are precisely needed to follow all injury claims following the federal worker's compensation framework. In the state worker's compensation, the dispute in the claims is litigated by a judge from the Office of Adjudication.


Tricare is a crucial health plan for military members, retirees, and beneficiaries with the inclusion of their family members. The Electronic Remittance Advance forms provide details of the claims payment. However, there can be cases of reimbursements and refunds which should be scrutinized to avoid mistakes. The federal workers' compensation and state workers' compensation were enacted to ensure employees receive benefits from employers in the event of an injury. Workers' compensation plans are crucial and therefore, due diligence is a crucial component in their administration.


Guyton, G. P. (1999). A brief history of workers' compensation. The Iowa orthopedic journal, 19, 106. Retrieved from:, S.K. & Linker, R. (2015). Understanding Medical Coding: A Comprehensive Guide. Cengage Learning.

Williamson, R.B. (2011). Defense Health Care: Access to Civilian Providers under TRICARE Standard and Extra. Diane Publishing.

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