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Blue Cross Blue shield Health Insurance Commercial Insurance CMS1500 Claim Form

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

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)

Is 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.

(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 CARE

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 PROSOECTIVE 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.

CMS-1500 LINE 9, 9A-9D

Leave blank unless there is a secondary insurance coverage

CMS-1500 LINE 11A

Enter the policy holders birth date as MM DD YYYY (with spaces)

CMS-1500 LINE 17

Enter the first name, middle initial, last name, and credentials of the professional who referred or ordered healthcare services (do not enter punctuation)

CMS-1500 LINE 18

Enter only if the patient had hospital care

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