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Chapter 8: Private Payers/BlueCross BlueShield
Terms in this set (26)
A BCBS program that provides benefits for plan subscribers who are away from their local areas.
BlueCross BlueShield Association (BCBS)
The national licensing agency of BlueCross and BlueShield plans
A part of a standard health plan that is changed under a negotiated employer-sponsored plan; also refers to subcontracting of coverage by a health plan.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer's group health plan for eighteen months after termination.
Periodic verification that a provider or facility meets the professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence.
Nonemergency surgical procedure that can be scheduled in advance.
Employee Retirement Income Security Act of 1974 (ERISA)
A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.
Fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.
Federal Employees Health Benefits (FEHB) program
The health insurance program that covers employees of the federal government.
The BCBS consumer-driven health plan funding opetion that has employer and employee contributions; funds left over revert to the employer.
group health plan (GHP)
Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide health care to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not group health plans.
A BCBS plan in the community where the subscriber has contracted for coverage.
A participating provider's local BCBS plan.
Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits from a payer begin.
individual health plan (IHP)
Medical Insurance plan purchased by an individual, rather than through a group affiliation.
Category of enrollment in a commercial health plan that may have different eligibility requirements.
maximum benefit limit
The amount an insurer agrees to pay for an insured's covered expenses over the course of the insured person's lifetime.
monthly enrollment list
Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.
open enrollment period
Span of time during which a policyholder selects from an employer's offered benefits; often used to describe the fourth quarter of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap plan.
Generally, preauthorizaiton for hospital admission or outpatient procedures.
Document that modifies an insurance contract.
self-insured health plan
An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay.
Protection against the risk of large losses or severely adverse claims experience; may be included in a participating provider's contract with a plan or bought by a self-funded plan.
The payer's process for determining medical necessity - whether the review is conducted before or after the services are provided.
utilization review organization (URO)
An organizaiton hired by the payer to evaluate the medical necessity of planned procedures.
An amount of time that must pass before a newly hired employee or a dependent is eligible to enroll in a health plan.
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