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