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Insurance Term

Billing and coding

Blue Preferred Plan Patient receives service at a discounted rate from a panel, or select group of physicians and other health care providers who participate in the program
CAREN computerized telephone inquiry system that provides information about a patient's eligibility, and benefits.
C.O.B program for determining which health insurer pays for services first when a subscriber is covered by more than one health care plan.
Contract Number The alpha numeric combination assigned to the person named on the ID card. 3 character must be included on the for,
Copayment This can be a set dollar amount based on contract benefits, or a percentage of the approved amount that the subscriber pays for medical services.
Customary Charge The charge which the physician or other provider usually charges for specific services
Deductible The amount that must be paid by a subscriber before an insurer begins to pay for medical services.
DENIS Dial in Eligibility Network and Information System- computer based system that gives you access to BCBSM through the internet to obtain information on patient's eligibility, benefits and claim's status.
Dependent person covered by the subscribers health care plan
CMS 1500 Claim form used to report services rendered for payment
HMO Health Maintenance Organization- Patients must choose a PCP who provides services, must obtain referrals to see specialist
Master Medical The coverage that extends and adds benefits to a patient's basic BCBS contract
Modifiers A two character code- either 2 numbers or an alphanumeric code to further clarify information about a CPT code to the insurance carrier
NASCO National Accounts Service Company- reprsents employers such as GM, Ford, and Chrysler to name a few
Non-Participating Physician Physician who has not entered into a written contract to accept BCBS payments as payment in full. Patient would be responsible for the difference in the payment and the physician's charged amount
Participating Physician Physician who has entered into a written contract with BCBS to accept the payment from BCBS as payment in full. Patient can only be charged deductibles, co pay, on non-contract benefit
Point of Service (Blue Choice) Similar to HMO except that subscribers may recieve partial coverage for services not authorized by the PCP
PPO (Blue Preferred Plan) Preferred Provider Organization- patients recieve services at a discounted rate from a select group of physicians and other health care providers who participate in the program. May be co pays`
Preauthorization Process of obtaining approval for a service through the individual's insurance company by establishing that it is medically necessary
Pre-existing condition Medical condition that existed befor a member's BCBS coverage became effective
Premium A dollar amount that is paid for insurance coverage eithe by the insured or by the employer
PIN Unique 10 digit number assigned by BCBS to providers to identify them
Subscriber Person who is enrolled in BCBS for health care coverage. This is the person whose name is listed on the card
NPI (National Provider ID) A unique 10 digit number assigned to providers to ID them on a CMS 1500 claim form.