Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
Instructor Manual
Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088;
Chapter 1: Health Insurance Specialist Career
TABLE OF CONTENTS
Purpose and Perspective of the Chapter......................................................................2
Chapter Objectives........................................................................................................2
Key Terms.....................................................................................................................2
What’s New in This Chapter........................................................................................5
Chapter Outline.............................................................................................................5
Discussion Questions....................................................................................................6
Additional Resources....................................................................................................6
Internet Resources......................................................................................................................................6
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 1
accessible website, in whole or in part.
, Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
PURPOSE AND PERSPECTIVE OF THE CHAPTER
The purpose of this chapter is to provide an overview of the health insurance claims process and the key
participants involved. It discusses the various career opportunities available for health insurance
specialists and outline the education and training necessary for success in this field. This chapters details
the essential job responsibilities of a health insurance specialist and clarifies the differences among types
of liability insurance acquired by employers and independent contractors. Additionally, it emphasizes the
importance of workplace professionalism, explains effective telephone communication skills in a
healthcare setting, and highlights professional associations and credentials related to coding and
reimbursement. This chapter serves as a foundation for understanding the multifaceted role of health
insurance specialists and the critical skills required for the profession.
CHAPTER OBJECTIVES
The following objectives are addressed in this chapter:
LO 1.1 Briefly summarize health insurance claims processing and the parties involved.
LO 1.2 Identify career opportunities available for health insurance specialists.
LO 1.3 List the education and training requirements of a health insurance specialist.
LO 1.4 Describe the job responsibilities of a health insurance specialist.
LO 1.5 Differentiate among types of liability insurance purchased by employers and independent
contractors.
LO 1.6 Explain the role of workplace professionalism for a health insurance specialist.
LO 1.7 Discuss telephone skills for the health care setting.
LO 1.8 Identify coding and reimbursement professional associations and credentials offered.
[return to top]
KEY TERMS
AAPC: Professional association, previously known as the American Academy of Professional Coders,
established to provide a national certification and credentialing process, to support the national and local
membership by providing educational products and opportunities to networks, and to increase and
promote national recognition and awareness of professional coding.
American Association of Medical Assistants (AAMA): Enables medical assisting professionals
to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients;
as well as protect medical assistants’ right to practice.
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 2
accessible website, in whole or in part.
, Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
American Health Information Management Association (AHIMA): Founded in 1928 to
improve the quality of medical records, and currently advances the health information management
(HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM
and ICD-10-PCS in 2013.
artificial intelligence (AI): Enables computer systems to perform tasks normally requiring human
intelligence (e.g., data analysis).
bonding insurance: An insurance agreement that guarantees repayment for financial losses resulting
from the act or failure to act of an employee. It protects the financial operations of the employer.
business liability insurance: Protects business assets and covers the cost of lawsuits resulting from
bodily injury, personal injury, and false advertising.
Centers for Medicare and Medicaid Services (CMS): Formerly known as the Health Care
Financing Administration (HCFA); an administrative agency within the federal Department of Health and
Human Services (DHHS).
claims examiner: Employed by third-party payers to review health-related claims to determine
whether the charges are reasonable and medically necessary based on the patient’s diagnosis.
coder: Coders apply a working knowledge of coding systems, including coding conventions and
guidelines, government regulations, and third-party payer requirements, to accurately assign ICD-10-
CM/PCS and CPT/ HCPCS Level II codes to diagnoses and procedures/services documented in medical
records.
coding: Process of reporting diagnoses, procedures, services, and supplies as numeric and alphanumeric
characters (called codes) on the insurance claim.
embezzle: The illegal transfer of money or property as a fraudulent action; to steal money from an
employer.
errors and omissions insurance: See professional liability insurance.
ethics: Principle of right or good conduct; rules that govern the conduct of members of a profession.
health care provider: Physician or other health care practitioner (e.g., physician’s assistant).
health information technician: Professionals who manage patient health information and medical
records, administer computer information systems, and code diagnoses and procedures for health care
services provided to patients.
health insurance claim: Documentation that is electronically or manually submitted to an insurance
plan requesting reimbursement for health care procedures and services provided (e.g., CMS-1500 and
UB-04 claims).
health insurance specialist: Person who reviews health related claims to match medical necessity
to procedures or services performed before payment (reimbursement) is made to the provider; see also
reimbursement specialist.
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 3
accessible website, in whole or in part.
, Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
hold harmless clause: Policy that the patient is not responsible for paying what the insurance plan
denies.
independent contractor: Defined by the ‘Lectric Law Library’s Lexicon as “a person who performs
services for another under an express or implied agreement and who is not subject to the other’s control,
or right to control, of the manner and means of performing the services. The organization that hires an
independent contractor is not liable for the acts or omissions of the independent contractor.”
internship: Nonpaid professional practice experience that benefits students and facilities that accept
students for placement; students receive on-the-job experience prior to graduation, and the internship assists
them in obtaining permanent employment.
medical assistant: Employed by a provider to perform administrative and clinical tasks that keep the
office or clinic running smoothly.
medical malpractice insurance: A type of liability insurance that covers physicians and other
health care professionals for liability claims arising from patient treatment.
medical necessity: Involves linking every procedure or service code reported on an insurance claim to
a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to
perform that procedure or service.
professional liability insurance: Provides protection from liability as a result of errors and
omissions when performing their professional services; also called errors and omissions insurance.
professionalism: Conduct or qualities that characterize a professional person.
property insurance: Protects business contents (e.g., buildings and equipment) against fire, theft, and
other risks.
reimbursement specialist: See health insurance specialist.
respondeat superior: Latin for “let the master answer”; legal doctrine holding that the employer is
liable for the actions and omissions of employees performed and committed within the scope of their
employment.
scope of practice: Health care services, determined by the state, that an NP and PA can perform.
[return to top]
WHAT’S NEW IN THIS CHAPTER
The following elements are improvements in this chapter from the previous edition:
Content about health occupations and artificial intelligence was updated.
[return to top]
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 4
accessible website, in whole or in part.
Career
Instructor Manual
Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088;
Chapter 1: Health Insurance Specialist Career
TABLE OF CONTENTS
Purpose and Perspective of the Chapter......................................................................2
Chapter Objectives........................................................................................................2
Key Terms.....................................................................................................................2
What’s New in This Chapter........................................................................................5
Chapter Outline.............................................................................................................5
Discussion Questions....................................................................................................6
Additional Resources....................................................................................................6
Internet Resources......................................................................................................................................6
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 1
accessible website, in whole or in part.
, Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
PURPOSE AND PERSPECTIVE OF THE CHAPTER
The purpose of this chapter is to provide an overview of the health insurance claims process and the key
participants involved. It discusses the various career opportunities available for health insurance
specialists and outline the education and training necessary for success in this field. This chapters details
the essential job responsibilities of a health insurance specialist and clarifies the differences among types
of liability insurance acquired by employers and independent contractors. Additionally, it emphasizes the
importance of workplace professionalism, explains effective telephone communication skills in a
healthcare setting, and highlights professional associations and credentials related to coding and
reimbursement. This chapter serves as a foundation for understanding the multifaceted role of health
insurance specialists and the critical skills required for the profession.
CHAPTER OBJECTIVES
The following objectives are addressed in this chapter:
LO 1.1 Briefly summarize health insurance claims processing and the parties involved.
LO 1.2 Identify career opportunities available for health insurance specialists.
LO 1.3 List the education and training requirements of a health insurance specialist.
LO 1.4 Describe the job responsibilities of a health insurance specialist.
LO 1.5 Differentiate among types of liability insurance purchased by employers and independent
contractors.
LO 1.6 Explain the role of workplace professionalism for a health insurance specialist.
LO 1.7 Discuss telephone skills for the health care setting.
LO 1.8 Identify coding and reimbursement professional associations and credentials offered.
[return to top]
KEY TERMS
AAPC: Professional association, previously known as the American Academy of Professional Coders,
established to provide a national certification and credentialing process, to support the national and local
membership by providing educational products and opportunities to networks, and to increase and
promote national recognition and awareness of professional coding.
American Association of Medical Assistants (AAMA): Enables medical assisting professionals
to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients;
as well as protect medical assistants’ right to practice.
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 2
accessible website, in whole or in part.
, Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
American Health Information Management Association (AHIMA): Founded in 1928 to
improve the quality of medical records, and currently advances the health information management
(HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM
and ICD-10-PCS in 2013.
artificial intelligence (AI): Enables computer systems to perform tasks normally requiring human
intelligence (e.g., data analysis).
bonding insurance: An insurance agreement that guarantees repayment for financial losses resulting
from the act or failure to act of an employee. It protects the financial operations of the employer.
business liability insurance: Protects business assets and covers the cost of lawsuits resulting from
bodily injury, personal injury, and false advertising.
Centers for Medicare and Medicaid Services (CMS): Formerly known as the Health Care
Financing Administration (HCFA); an administrative agency within the federal Department of Health and
Human Services (DHHS).
claims examiner: Employed by third-party payers to review health-related claims to determine
whether the charges are reasonable and medically necessary based on the patient’s diagnosis.
coder: Coders apply a working knowledge of coding systems, including coding conventions and
guidelines, government regulations, and third-party payer requirements, to accurately assign ICD-10-
CM/PCS and CPT/ HCPCS Level II codes to diagnoses and procedures/services documented in medical
records.
coding: Process of reporting diagnoses, procedures, services, and supplies as numeric and alphanumeric
characters (called codes) on the insurance claim.
embezzle: The illegal transfer of money or property as a fraudulent action; to steal money from an
employer.
errors and omissions insurance: See professional liability insurance.
ethics: Principle of right or good conduct; rules that govern the conduct of members of a profession.
health care provider: Physician or other health care practitioner (e.g., physician’s assistant).
health information technician: Professionals who manage patient health information and medical
records, administer computer information systems, and code diagnoses and procedures for health care
services provided to patients.
health insurance claim: Documentation that is electronically or manually submitted to an insurance
plan requesting reimbursement for health care procedures and services provided (e.g., CMS-1500 and
UB-04 claims).
health insurance specialist: Person who reviews health related claims to match medical necessity
to procedures or services performed before payment (reimbursement) is made to the provider; see also
reimbursement specialist.
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 3
accessible website, in whole or in part.
, Instructor Manual: Green, Understanding Health Insurance, 2026 Edition, ©2027, 9798214482088; Chapter 1: Health Insurance Specialist
Career
hold harmless clause: Policy that the patient is not responsible for paying what the insurance plan
denies.
independent contractor: Defined by the ‘Lectric Law Library’s Lexicon as “a person who performs
services for another under an express or implied agreement and who is not subject to the other’s control,
or right to control, of the manner and means of performing the services. The organization that hires an
independent contractor is not liable for the acts or omissions of the independent contractor.”
internship: Nonpaid professional practice experience that benefits students and facilities that accept
students for placement; students receive on-the-job experience prior to graduation, and the internship assists
them in obtaining permanent employment.
medical assistant: Employed by a provider to perform administrative and clinical tasks that keep the
office or clinic running smoothly.
medical malpractice insurance: A type of liability insurance that covers physicians and other
health care professionals for liability claims arising from patient treatment.
medical necessity: Involves linking every procedure or service code reported on an insurance claim to
a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to
perform that procedure or service.
professional liability insurance: Provides protection from liability as a result of errors and
omissions when performing their professional services; also called errors and omissions insurance.
professionalism: Conduct or qualities that characterize a professional person.
property insurance: Protects business contents (e.g., buildings and equipment) against fire, theft, and
other risks.
reimbursement specialist: See health insurance specialist.
respondeat superior: Latin for “let the master answer”; legal doctrine holding that the employer is
liable for the actions and omissions of employees performed and committed within the scope of their
employment.
scope of practice: Health care services, determined by the state, that an NP and PA can perform.
[return to top]
WHAT’S NEW IN THIS CHAPTER
The following elements are improvements in this chapter from the previous edition:
Content about health occupations and artificial intelligence was updated.
[return to top]
a
© 2027 Cengage Learning, Inc. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly 4
accessible website, in whole or in part.
