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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE: 

Explain the concept of coding as used in Healthcare Benefits Administration 
SAQA US ID UNIT STANDARD TITLE
12314  Explain the concept of coding as used in Healthcare Benefits Administration 
ORIGINATOR
SGB Financial Services 
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
Passed the End Date -
Status was "Registered" 
2001-12-05  2004-12-02  SAQA 0639/01 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2005-12-02   2008-12-02  

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 is replaced by: 
US ID Unit Standard Title Pre-2009 NQF Level NQF Level Credits Replacement Status
117215  Explain the use of coding in Healthcare Benefits Administration  Level 4  NQF Level 04   

PURPOSE OF THE UNIT STANDARD 
This unit standard introduces the concept of coding as used in Healthcare Benefits Administration by medical claims assessors.

The qualifying learner is capable of:
  • Explaining the concept of coding as used by Healthcare Benefits Administrators.
  • Explaining purpose of procedural, diagnostic and consumable coding systems.
  • Explaining the concept of rules and conventions as applied in the use of coding systems.
  • Applying a procedural coding system in assessing a claim. 

  • 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:

    1.Categories for codes are procedural, diagnostic and consumable. 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Demonstrate knowledge & understanding of the concept of coding. 
    OUTCOME NOTES 
    Demonstrate knowledge and understanding of the concept of coding in Healthcare Benefits Administration. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    1. The purpose of a coding system is explained and an indication given of why Healthcare Benefits Administrators use a coding system. 

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

    ASSESSMENT CRITERION 3 
    3. The implications of the incorrect use of a coding system are explained in terms of the effect on the payment of a claim. 

    ASSESSMENT CRITERION 4 
    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 
    Demonstrate knowledge and understanding of procedural coding systems. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    1. The different procedural coding systems in use in Healthcare Benefits Administration are listed and an indication given of the internal system used by a particular Healthcare Benefits Administrator. 

    ASSESSMENT CRITERION 2 
    2. The purpose of using a procedural coding system is explained with reference to two procedural coding systems. 

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

    SPECIFIC OUTCOME 3 
    Demonstrate knowledge and understanding of diagnostic coding systems. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    1. The different diagnostic coding systems in use in Healthcare Benefits Administration are listed and an indication given of the internal system used by a particular Healthcare Benefits Administrator. 

    ASSESSMENT CRITERION 2 
    2. The purpose of using a diagnostic coding system is explained with reference to two diagnostic coding systems. 

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

    SPECIFIC OUTCOME 4 
    Demonstrate knowledge and understanding of consumable coding systems. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    1. The different consumable coding systems in use in Healthcare Benefits Administration are listed and an indication given of the internal system used by a particular Healthcare Benefits Administrator. 

    ASSESSMENT CRITERION 2 
    2. The purpose of using a consumable coding system is explained with reference to two consumable coding systems. 

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

    SPECIFIC OUTCOME 5 
    Apply a procedural coding system in assessing a claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    1. The supplied code is validated as the correct code. 

    ASSESSMENT CRITERION 2 
    2. Administrator protocols are known and applied to incorrect codes. 

    ASSESSMENT CRITERION 3 
    3. Codes used on provider accounts are checked for appropriateness in the context of diagnosis, specialty and treatment. 

    ASSESSMENT CRITERION 4 
    4. Fee charges are validated against the schemes tariff rules. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This unit standard will be internally assessed by the provider and moderated by a moderator registered by INSQA or a relevant accredited ETQA. The mechanisms and requirements for moderation are contained in the document obtainable from INSQA, - INSQA framework for assessment and moderation. 


    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 ORGANISING 
    The learner is able to organise and manage him/herself effectively by becoming responsible citizens in applying codes in assessing medical claims accurately and fairly. 

    UNIT STANDARD CCFO COLLECTING 
    The learner is able to collect, organise and critically evaluate information in order to apply codes and process a medical claim. 

    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 and critically showing responsibility towards the environment and the health of others in using a computer system to access and apply codes in assessing a claim. 

    UNIT STANDARD CCFO DEMONSTRATING 
    The learner is able to demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation in understanding the effect of the incorrect use of codes in the payment of a claim. 

    UNIT STANDARD NOTES 
    This unit standard has been replaced by 117215, which is 'Explain the use of coding in Healthcare Benefits Administration', Level 4, 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  20639   National Certificate: Healthcare Benefits Administration: Claims Assessing  Level 4  NQF Level 04  Passed the End Date -
    Status was "Registered" 
    2004-12-05  INSETA 
    Elective  48493   National Certificate: Financial Services: Wealth Management  Level 4  NQF Level 04  Passed the End Date -
    Status was "Registered" 
    2007-02-11  Was INSETA until Last Date for Achievement 


    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. Discovery Life Ltd 
    2. Faisit (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.