NHA CBCS Course Notes

Know the full revenue cycle, communicate accurately with patients/providers/payers, protect PHI under HIPAA's actual payment rules, and recognize fraud/abuse/compliance risks before they become claims.

• Treating every HIPAA disclosure as requiring authorization.

• Think process before payment.

Verify the plan and documentation, understand benefit/cost-sharing terms, determine COB filing order, and apply payer-specific referral/prior-authorization rules without making coverage promises.

• Provider becomes payer under AOB.

• Payer → plan → patient → service → rule.

Second-largest domain. Abstract only supported facts, choose the correct code system for the setting, apply official ICD/CPT/HCPCS conventions and modifier logic, and resolve documentation/medical-necessity gaps without changing clinical meaning.

• HCPCS means 'everything except CPT.'

• Setting + service type + documentation = coding path.

Largest domain. Build clean professional claims from documentation, transmit and scrub correctly, interpret remittance, post/reconcile accurately, and resolve rejects/denials/A-R through the correct payer path.

• 835 called a claim.

• Document → scrub → submit → status → adjudicate → post → resolve.