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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Explain the use of coding in Healthcare Benefits Administration 
SAQA US ID UNIT STANDARD TITLE
117215  Explain the use of coding in Healthcare Benefits Administration 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 4  NQF Level 04 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard replaces: 
US ID Unit Standard Title Pre-2009 NQF Level NQF Level Credits Replacement Status
12314  Explain the concept of coding as used in Healthcare Benefits Administration  Level 4  NQF Level 04  Complete 

PURPOSE OF THE UNIT STANDARD 
This unit standard introduces the concept of coding as used in Healthcare Benefits Administration. It is useful for medical claims assessors, medical practitioners and intermediaries.

The qualifying learner is capable of:
  • Explaining the concept of coding as used by Healthcare Benefits Administration.
  • Explaining the diagnostic coding system.
  • Explaining the procedural coding system.
  • Explaining consumable coding systems.
  • Apply knowledge of medical terminology, anatomy and physiology to the use of coding systems. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    There is open access to this unit standard. Learners should be competent in Communication and Mathematical Literacy at Level 3. 

    UNIT STANDARD RANGE 
    The typical scope of this unit standard is:
  • The purpose of using a standardised international code includes, but is not limited to, research, payment of claims, building a data base, predicting epidemics and monitoring trends.
  • Consumable codes include, but are not limited to, NAPPI codes and chargeable codes.
  • Prefixes and suffixes include, but are not limited to, common medical abbreviations and combination terminology. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Explain the concept of coding in Healthcare Benefits Administration. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The purpose of using a standardised international a coding system is explained with examples. 

    ASSESSMENT CRITERION 2 
    The categories used for coding systems are named with examples. 

    ASSESSMENT CRITERION 3 
    The implications of the incorrect use of a coding system are explained and an indication is given of who is responsible for ensuring the code on the account is correct. 

    ASSESSMENT CRITERION 4 
    Events that would result in a coding system being revised or changed are named and an indication given of when amendments were made to the currently used codes. 

    SPECIFIC OUTCOME 2 
    Explain the diagnostic coding system. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The diagnostic coding system used in Healthcare Benefits Administration is identified and an indication given of the information contained in the code. 

    ASSESSMENT CRITERION 2 
    The concept of rules and conventions in the use of diagnostic codes is explained with examples. 

    ASSESSMENT CRITERION 3 
    The diagnostic code is interpreted for three case studies. 

    ASSESSMENT CRITERION 4 
    The use of the diagnostic code is applied to case studies. 

    SPECIFIC OUTCOME 3 
    Explain the procedural coding system. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The procedural coding system used in Healthcare Benefits Administration is identified and an indication is given of the kind of information contained in the code. 

    ASSESSMENT CRITERION 2 
    The relationship between the diagnostic and procedural is explained with examples. 

    ASSESSMENT CRITERION 3 
    The concept of rules and conventions in the use of procedural codes is explained with examples. 

    ASSESSMENT CRITERION 4 
    The procedural code is applied to case studies. 

    SPECIFIC OUTCOME 4 
    Explain consumable coding systems. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The different consumable coding systems in use in Healthcare Benefits Administration are identified and an indication given of the purpose of each code. 

    ASSESSMENT CRITERION 2 
    The concept of rules and conventions in the use of consumable codes is explained with examples. 

    ASSESSMENT CRITERION 3 
    The difference between NAPPI codes and chargeable codes is explained with examples. 

    ASSESSMENT CRITERION 4 
    The relationship between the procedural code, diagnostic code and consumable code is explained with examples. 

    SPECIFIC OUTCOME 5 
    Apply knowledge of medical terminology, anatomy and physiology to the use of coding systems. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Common prefixes and suffixes used in medical terminology are identified and used to create an understanding of medical terminology. 

    ASSESSMENT CRITERION 2 
    Knowledge of basic anatomy and physiology of the human body is applied to to the use and conventions of coding systems. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This Unit Standard will be internally assessed by the provider and moderated by a moderator registered by a relevant accredited ETQA or an ETQA that has a Memorandum of Understanding with the relevant accredited ETQA. 

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    The learner is able to identify and solve problems in identifying irregularities in codes used by providers and possible instances of fraudulent claims. 

    UNIT STANDARD CCFO COMMUNICATING 
    The learner is able to communicate effectively using language skills as these are built into many of the assessment criteria. 

    UNIT STANDARD CCFO SCIENCE 
    The learner is able to use science and technology effectively in using a computer system to access and apply codes. 

    UNIT STANDARD CCFO DEMONSTRATING 
    The learner is able to demonstrate an understanding of the world as a set of related systems in understanding the effect of the incorrect use of codes in the payment of a claim. 

    UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    This unit standard has replaced 12314 which was "Explain the concept of coding as used in Healthcare Benefits Administration", Level 4 with 4 credits 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  49356   Further Education and Training Certificate: Medical Claims Assessing  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  49089   National Certificate: Financial Services  Level 3  NQF Level 03  Reregistered  2023-06-30  INSETA 
    Elective  49649   Further Education and Training Certificate: Long-term Insurance  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  57613   Further Education and Training Certificate: Short-Term Risk Management  Level 4  NQF Level 04  Passed the End Date -
    Status was "Reregistered" 
    2012-06-30  INSETA 
    Elective  66613   Further Education and Training Certificate: Wealth Management  Level 4  NQF Level 04  Reregistered  2021-06-30  As per Learning Programmes recorded against this Qual 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    1. African Resources & Financial Training (Pty) Ltd 
    2. ALCARI 233 CC T/A ALCARI (Eversdal)(TP) 
    3. CKP Development Agency (Pty) Ltd. 
    4. De Vries Management & Training Services cc 
    5. DSBI (Pty) Ltd 
    6. Duxah (Pty) Ltd 
    7. Faisit (Pty) Ltd 
    8. Intec College 
    9. Masifunde Training Centre (Pty) Ltd 
    10. Old Mutual Life Assurance Company South Africa 
    11. Ray Strodl Consulting (Pty) Ltd 
    12. RJM Educational Consulting PTY LTD 
    13. Sanlam Life Insurance Ltd 
    14. Sanlam Life Insurance Ltd. 
    15. The Institute of Health Risk Managers (Pty) Ltd 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.