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Blue Cross Blue Shield

Blue Cross 1929 Baylor University Hospital, Dallas, TX
Blue Shield 1939 Palo Alto, CA
Merge of BC & BS 1977
Non-profit Pay no taxes on profits generated by the corporation.
For-profit Pays taxes on profits generated by the corporation
Features of BCBS Prompt direct payments, maintain regional prof. rep to assist with claim problems, provide educational seminars, workshops and newsletters.
Non-profits in exchange of tax relief are forbidden of what? Cancelling coverage due to poor health or exceeding the average.
Non-profits can cancel for what reasons? Unpaid premiums, fraud on application.
Participating Provider A healthcare provider who enters into a contract with BCBS and agrees to their regulations.
PPN (Preferred Provider Network) Agrees to accept the PPN allowed rate (generally 10% lower)
BCBS Plans Fee for service, Indemnity, Managed Care Plans, Federal Employee Program, Medicare Supplemental Plans, Healthcare Anywhere
Medicare Supplemental Plans Medigap
Fee for Service Basic and Major Medical
Basic BCBS Hospitalizations, Diagnostic Lab, Surgical Fees, X-Rays, Assistant Surgeon Fees, Obstetrics, Chemotherapy, Intensive Care, Newborn Care
Major Medical BCBS Office Visits, Outpatient nonsurgical, Physical and occupational therapy, Durable med equipment, Mental Health Visits, Allergy testing and injections, Rx, Private duty nursing, Dental Care
Rider Additional coverage over and above standard contract.
Special Accidental Injury Rider Covers 100% of nonsurgical care sought withing 24 to 72 hours of injury.
Medical Emergency Care Rider Covers immediate treatment to prevent permanent impairment or dysfunction of an organ or body part.
Indemnity Offers choice and flexibility, freedom to use any licensed provider
Managed Care Plans Provides health care and controls costs through network of physicians and hospitals
Coordinated Home Health and Hospice Care Alternative to traditional hospital
OPAP (Outpatient pretreatment Authorization Plan Requires preauthorization of outpatient physical, occupational and speech therapy services
OPAP (Outpatient pretreatment Authorization Plan) AKA precertification/prospective authorization
Member Policyholder
Second Surgical Opinion (SSO) Requirement for elective nonemergency surgical care
Federal Employee Program (FEP) 3 digit code on ID card specifies what plan is elected.
Healthcare Anywhere Allows members to have access to healthcare benefits throughout the U.S. and around the world.
Away From Home Care Program Allows those residing outside of their home for at least 90 days to temporarily enroll with a local HMO.
Claims Processing BCBS processes their own claims
Deadline for filing Claims 1 year from date of service
Forms used CMS 1500
UCR Usual, customary, reasonable (common charges within a particular geographic region)
Assignment of Benefits Payment is made directly to the provider by BCBS
Purchase Noncancellation Plan clause can not be dropped
ICD-9 Codes Listed in order of severity (up to 4 codes)
CPT Codes Descending order of complexity (current procedural terminology)
Changing Business Structure Nonprofit corporations petitioned state legislatures to allow them to change from non profit to for profit.
Secondary Coverage When the same BCBS payer issues the primary and secondary or supplemental policies only one CMS-1500 form submitted.
Created by: ROSSMIBOA
Popular Insurance sets




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