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BLUE CROSS BLUE SHIELD
MEDICAL INSURANCE

They began a two separate prepaid health plans selling contracts to individuals or groups for coverage of specified medical expenses

THE BLUE CROSS SYMBOL
MEDICAL INSURANCE

Was first used in 1933 by the St. Paul, Minnesota plan & was adopted in 1939 by the AMA when it became the approving agency for accreditation of new prepaid hospitalization plans

THE BLUE SHIELD

Plans began as a resolution passed by the House of Delegates at an AMA meeting in 1938

PALO ALTO, CALIFORNIA

Where the first known plan was formed

BLUE CROSS PLANS

Originally covered only hospital bills

BLUE SHIELD PLANS

Originally covered fees for physician services

1977

Blue Cross Blue Shield national association voted to combine personnel under one leadership

1986

Blue Cross Blue Shield merged into one corporation. Named blue cross blue shield association

NONPROFIT CORPORATIONS

Are charitable, educational, civic, or humanitarian organizations whose profits are returned to the program of the corporation

FOR-PROFIT CORPORATIONS

Pay taxes on profits generated by the corporation's enterprises and pay dividends to shareholders on after-tax profits

BCBS DISTINCTIVE FEATURES

Make prompt, direct payment of claims.
*Maintain regional professional representatives to assist participating providers with claim problems
*Provide educational resources to keep providers up to date on insurance procedures

BCBS POLICIES CAN ONLY BE CANCELLED WHEN

*Premiums are not paid.
*If the plan can prove fraudulent statements were made on the application for coverage

PARTICIPATING PROVIDER (PAR)

a healthcare provider who enters into a contract with BCBS corporation

PREFERRED PROVIDER NETWORK (PPN)

A program that requires providers to adhere to managed care provisions

NONPARTICIPATING PROVIDERS (nonPARs)

Have not signed participating provider contracts, and they expect to be paid the full fee charged for services rendered.Paid 5% less

(6) BCBS PLANS

Fee for Service, Indemnity, Managed Care Plans, Federal Employee Program (FEP), Medicare supplemental plans, Healthcare Anywhere.

BCBS BASIC COVERAGE

Hospitalizations, Diagnostic Lab Service, X-Rays, Surgical Fees, Assistant surgeon fees, Obstetric care, Intensive care, Newborn care, * Chemotherapy for cancer

RIDERS

Are special clauses stipulating additional coverage over and above the standard contract.

SPECIAL ACCIDENTAL INJURY RIDER

Covers 100% of nonsurgical care sought and rendered within 24 to 72 hours of the accidental injury

MEDICAL EMERGENCY CARE RIDER

Covers immediate treatment sought and received for sudden, severe and unexpected conditions that if not treated would place the patient's health in permanent jeopardy

COORDINATED HOME HEALTH & HOSPICE CAR

Program that allows patients with this option to elect an alternative to the acute care setting.

OUTPATIENT PRETREATMENT AUTHORIZATION PLAN (OPAP)

is a requirement for the delivery of certain healthcare services and is issued prior to the provision of services PROSPECTIVE AUTHORIZATION or PRECERTIFICATION

MEMBER

is also known as a subscriber

SECOND SURGICAL OPINION (SSO)

Requirement is necessary when a patient is considering elective, nonemergency surgical care.

FEP CARDS (FEDERAL EMPLOYEE PROGRAM)

Dependents names do not appear on the care. A 3 digit enrollment code is located on the front of the card to specify the options elected. This code should be entered as the group ID# on BCBS claims.

CLAIMS DEADLINE

One year from the date of service

DEDUCTIBLE

Will vary according to the BCBS plan

COPAYMENT/COINSURANCE

Patient requirements vary according to the patient plan. The most common coinsurance amounts are 20% or 25%

USUAL, CUSTOMARY, AND REASONABLE (UCR

Basis, which is the amount commonly charged for a particular medical service by providers

ASSIGNMENT OF BENEFITS

All claims filed by participating providers qualify for an assignment of benefits to the provider. This means that payment is made directly to the provider by BCBS

Federal Employee Programs

101 Individual High Option
102 Family High Option
104 Individual Low Option
105 Family Low Option

HMO

"Gate Keeper" Choose Primary Care giver stay in network

POS

Go in and out of network, but pay more for service

PPO

No Primary , but you need to stay in network

Fee for service

First 80/20 basic coverage

Indemnity Coverage

Hospital only coverage

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