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Mod 1A UHI BCBS
Blue Cross Blue Shield
| Question | Answer |
|---|---|
| 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
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