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34 terms

BLUE CROSS/ BLUE SHIELD

Blue Cross Blue shield Health Insurance Commercial Insurance CMS1500 Claim Form
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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
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