billing 12 &13

Created by delilah_lozier 

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Ch. 12-13

Prior to the joint venture between Blue Cros and Blue Shield, the Blue Shield plans only covered__________.

physician services

Blue Cross facilities that had signed contracts to provide services to subscribers for special rates were known as _________ hospitals.

member

In what year was the Blue Cross Blue Shield Association (BCBSA) created?

1968

Which is a function of the Blue Cross Blue Shield Association (BCBSA)?

hiring local personnel

The difference between for-profit status and nonprofit status is_____________________.

for-profit corporations pay taxes on profits generated by the corporation

When apolicyholder moves into an area served by a different BCBS corporation than the policyholder previously used, the plan must___________________________.

allow conversion and guarantee transfer of membership

The preferred provider network (PPN) allowed rate is generally_____________.

10 percent lower than the participating provider rate

What is an incentive for a provider to sign a PPN contract?

written notification of new employer groups and hospitals

Small businesses are likely to select which BCBS coverage?

fee-for-service

An example of a benefit provided by BCBS basic coverage is_________________.

assistant surgeon fees

The BCBS plan type that offers choice and flexibility to subscribers is______________.

indemnity coverage

A special accidental injury rider provides which benefit?

Nonsurgical care is paid at 100% if treatment is received within the contracts established time frame.

What special handling is required for BCBS claims filed under the medical emergency care rider?

The ICD-9-CM codes must reflect a condition that requires immediate care.

The outpatient pretreatment authorization plan (OPAP) is also known as __________.

precertification

What title is listed on the BCBS identification cards for federal employees?

Government-Wide Service Benefit Plan

BCBS Medicare supplemental plans are also known as _________ plans.

Medigap

The BlueCard Program allows members to obtain health services while in another BCBS service area. The patient will also__________.

receive the benefits of his or her home plan contract

Which BCBS program or plan would be most appropriate for a student who is attending school out of state?

Away from Home Care Program

What information is entered in block 13 of a BCBS CMS-1500 claim form?

nothing: the box is left blank

The name of the _________ is entered in box 17.

referring physician

What is considered a commercial health insurance company?

Prudential

Another term that can be used to indicate a fee-for-service plan is a _______ plan.

noncapitated

When CPT code 99070 is reported in Block 24D on the CMS-1500 claim, information that discribes 99070 is entered into which block?

Block 19

How are primary and secondary insurances in a family determined?

The birthday rule states that whichever policyholder has the earliest birth year will be primary and the other secondary.

When the patient is the domestic partner of the primary policyholder, this id indicated on the CMS-1500 claim form by_________.

placing an X in the OTHER box of Block 6

Reimbursement for income lost as a result of a temporary or permanent illness or injury is covered by __________ insurance.

disability

What is entered in Block 14 of the CMS-1500 claim form?

Date patient first experienced signs or symptoms of present illness or injury or date of Last Menstrual Period.

What is entered in Block 17B of the CMS-1500 claim form?

National Provider Identifier (NPI)

When a patients blood sample is sent to an outside lab, Block 24D will indicate it as procedures and services performed and the ___________________________________.

Outside provider`s NPI is entered in Block 24J of the CMS-1500 claim form as the provider who performed the service

If the patient paid a copayment on the claim being submitted, this is indicated on the CMS-1500 claim form by entering amount paid in____________.

Block 29

If a patient is required to optain authorization to be treated by a specialist, where is this authorization number entered in the CMS-1500 claim form?

Block 23

When an insurance claim is submitted to an insurance company that covers the treatment of injuries sustained in a motor vehicle accident, the _________ reviews the claim and determines coverage for the injured person.

medical adjuster

Patient wishes to have payment from the health insurance company sent directly to her provider. How is this indicated on the CMS-1500 claim form?

Patient will sign Block 12

What is the correct way to enter the provider`s name and credentials in Block 31?

JOHN BROWN MD

If a patient has a credit or a negative balance what is entered in block 30?

leave blank

A secondary health insurance plan generally provides coverage that is ___________________.

intended for copayments and coinsurance only

When laboratory tests are performed in the office how is this reported?

enter an X in the NO box of Block 20

Reimbursement for loss of or damage to a vehicle caused by fire, flood, hail, theft, vandalism, or wind is covered by _________ automobile insurance.

comprehensive

Where is a paid copayment indicated?

Block 29

What is entered in Block 33A if the provider is part of a group practice?

National Provider Identifier (NPI)

What does PPN stand for?

Preferred Provider Network

What does SSO stand for?

Second Surgical Opinion

What does OPAP stand for?

Outpatient Pretreatment Authorization Plan

POS stands for__________.

Point of Servive

PPO stands for ____________.

Preferred Provider Organization

FEP stands for___________________.

Federal Employee Program

NPI stands for_______________.

National Provider Identifier

SOF stands for _________________.

Signiture On File

OASIS stands for ________________.

Outcomes and Assessment Information Set

What is HH PPS?

Home Health Prospective Payment System

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