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58 Cards in this Set

  • Front
  • Back
What is Primary Insurance?
the first insurance you bill
What is a Second Surgical Opinion?
2nd opinion for elective surgery
Non-Profit Organization
Charitable; Profits are returned to program of the corporation
For-Profit
Make $; Pay taxes on profits; $ to shareholders
UCR stand for?
Usual Customary & Reasonable
What is UCR?
Amount charged for particular service
Provider must adjust the balance between>> plan determined amount & the amount billed
pay FULL for uncovered services
What is Fee for Service?
Pay directly for each service;
NO network;
HIGHER co-pays & deductibles
What is Point Of Service?
based on managed care;
allows patients to choose whether they want to go to a dr in or out of network; out of network-cost more
Preferred Povider
Sign contract w/insurance & accept rate
>>>In return will notify new PPN participators in Directory
what are deductibles
the amount you must pay out-of-pocket before medical coverage kicks in
Exclusive Provider (EPO)
Allows out of network but pt must pay full price;
>>NO referral to see specialist
Non-Cancellation Clause
As long as you pay, they wont cancel you
Participating Provider (PAR)
health care who signs a contract
office accepts insurance as payment
Balance Billing
NON-participators bill pt difference between insurance allowed amount & the actual service fee
Medigap
Supplemental plans provide coverage for medical expenses not covered
>>it pays deductibles & co-pays
Federal Employee Program
coverage for federal government employees;operated as PPO plan.
Outpatient Pretreatment Authorization
Confirming eligibility & collecting info before inpatient admissions
Special clauses for additional coverage over and above the standard contract
Riders
Before Blue Cross and Blue Shield joined, the Blue Shield plans covered only:
physician services
The preferred provider network allowed rate is generally:
10 percent lower than the participating provider rate
What BCBS plan type offers the most flexibility for subscribers?
indemnity coverage
One of the expectations that nonparticipating provider has is to_____for services rendered:
obtain payment for the full fee charged
Which is a program that requires providers to adhere to managed care provisions
preferred provider network (PPN)
Which is considered a minimum benefit under BCBS BASIC coverage?
-Hospitalization -Surgical Fees
-Xrays -Newborn Care
-intensive Care -Labs
Which is considered a service reimbursed by BCBS major medical coverage?
-Mental Health Visits
-Office Visits
-Physical/Occupational Therapy
-Outpatient NON-surgical
The amount commonly charged for a particular medical service by providers within a particular geographic region for establishing their allowable rates
usual, customary,and reasonable (UCR)
Claims must be filed within
One year from the date of service
BCBS files their own ________.
Claims
OPAP
Outpatient Petreatment Authorization Program
Annual Deductible
meet deductible (out-of-pocket) before insurance will cover.
Commercial Supplemental Policy
works with primary, covers what primary doesn't
Policy Cancellation
insurance cancel policy
Chronic Condition
disease wont go away
Assignment of Benefits
payment made directly to provider by BCBS
student reporting?
every semester
sequencing of codes?
higher cost first, descending order
Who was BlueCross originally for?
teachers
Where did Blue cross start?
Dallas, TX
where did Blue Shield originate?
palo alto, CA
Term for policy holder
members
when filing claim in dr. office
Remittance advice
Special accidental injury rider
covers 100% nonsurgical care within 24 to 72 hours
Medical emergency care rider
for immediate treatment that would cause a permanent injury if not attended to.
When did BC and BS merge and what was the name?
1986- BlueCross BlueShield Association
American Hospital Association (AHA)- What does it do?
approving agency for new prepaid hospitalization plans
BCBS programs
-Fee for service -Federal Employee
-Managed Care -Healthcare Anywhere
-Indemnity -Medicare Supplemental
originally blue SHIELD only covered
physician
a health care delivery system that provides health care & controls costs thru network of physicians
managed care
Hospital-only or comprehensive hospital and medical coverage is considered ______ coverage
indemnity
Rebill BCBS claims not paid within __ days
30
Physicians who have not signed contracts with BCBS are considered
nonparticipating
Coverage beyond the BCBS basic coverage is offered through ___ coverage
major medical
T/F
BSBC serves as primary contractor for medicare hospital, hospice and health care services
TRUE
The outpatient pretreatment authorization plan (OPAP) is also known as
prospective authorization precertification preauthorization
A company that provides administrative services to health care plans is a(n)
third-party administratorTPA
originally Blue Cross only covered what bills?
Hospital
t/f
BCBS must obtain approval from state insurance commissioner for rate increases that affect all members in a state
TRUE
The letter R followed by eight numeric digits is the FEP
identification number