Question 1

The following are services that BCBS agrees to provide in exchange for provider contracts:

Accepted Answer

Direct paymetn to PARs,
Training sessions for PAR billing staff,
Free billing manuals and PAR newsletters, 
Representative to assist with billing/payment problems, 
Publishing directory of all PARs

Question 2

BCBS began as

Accepted Answer

two prepaid health plans

Question 3

"Usual, customary and reasonable basis" refers to

Accepted Answer

the amount commonly charged for a particular medical service by providers within a particular geographic region for establishing their allowable rates.

Question 4

BCBS fee-for-service is also known as

Accepted Answer

Traditional coverage

Question 5

An emergency rider would be necessary to

Accepted Answer

cover immediate treatment sought and received for sudden, severe, and unexpected conditions that if left untreated would put the patient's health in permanent jeopardy or cause permanent damage o fan organ or body part.

Question 6

PCP

Accepted Answer

primary care provider or primary care physician or personal care provider

Question 7

The Away from Home Care Plan

Accepted Answer

allows members who are temporarily living outside their HMO service are for at least 90 days  to temporarily enroll with a local HMO.

Question 8

BCBS is a

Accepted Answer

subscriber-driven program

Question 9

BCBS indemnity coverage

Accepted Answer

offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed healthcare provider of their choice.

Question 10

PPN

Accepted Answer

preferred provider network , they require providers to adhere to (or follow) managed care provisions

Question 11

BCBS must allow

Accepted Answer

conversion from one plan to another when the policy holder moves into an area served by a different BCBS corporation

Question 12

For-profit commercial plans

Accepted Answer

have the right to cancel policy at renewal time if the patient is a high user of benefits

Question 13

The outpatient pretreatment authorization plan (OPAP)

Accepted Answer

requires preauthorization of physical, occupational and speech therapy services

Question 14

A non-PAR is allowed to

Accepted Answer

ask a patient for payment in full on the day of service

Question 15

AHA

Accepted Answer

American Hospital Association...they are the approving agency for accreditation of new prepaid hospital plans

Question 16

Coordinated home health and hospice care are considered

Accepted Answer

alternatives to acute care setting

Question 17

Acute respiratory infection or bladder infection are

Accepted Answer

NOT considered emergency diagnosis

Question 18

FEHBP

Accepted Answer

Federal Employee Health Benefits Program

Question 19

Mandatory second surgical opinion requirement is necessary when a patient when a patient is

Accepted Answer

considering elective, non emergency surgical care

Question 20

Mental health benefits are considered a

Accepted Answer

BCBS major medical benefit

Question 21

Participating Providers (PARs) agree to write off (adjust) the difference or balance between

Accepted Answer

between the amount charged by the provider and the approved fee established by the provider (allowed amount)

Question 22

OPAP deals with

Accepted Answer

prospective authorization

Question 23

Riders are special clauses stipulating

Accepted Answer

additional coverage over and above the standard contract

Question 24

Indemnity coverage allows

Accepted Answer

the insured freedom to use any licensed healthcare provider

Question 25

BCBS corporations conduct

Accepted Answer

regular training sessions for PAR billing staff

Question 26

Blue Cross plans began in

Accepted Answer

1929 and provided coverage for hospital bills

Question 27

BCBS has to gain approval from their

Accepted Answer

state insurance commissioners for any rate increases and /or benefit changes

Question 28

Blue Sheild originated in

Accepted Answer

1938 and covered physician services

Question 29

For-profit corporations pay taxes on

Accepted Answer

profits generated by the corporation's enterprises and pay dividents to shareholders on after-tax profits

Question 30

When completing secondary claims you should

Accepted Answer

attach the R.A. (remittance advice)

Question 31

BCBS includes the following programs:

Accepted Answer

Fee-for-service,
Managed Care Plans,
Medicare Supplemental Plans

Question 32

BCBS claims filing deadline is

Accepted Answer

one year from the DOS (date of service)

Question 33

Federal Employee Health Benefits Program issues

Accepted Answer

insurance identification numbers that begin with the letter "R"

Question 34

The most common coinsurance amounts range between

Accepted Answer

20-25%

Question 35

EPO (Exclusive Provider Organization) is

Accepted Answer

similar to HMO but more restrictive

Question 36

Blue Worldwide Expat-

Accepted Answer

provides medical coverage for employees and dependents who spend more than 6 months outside the U.S.

Question 37

A special accident injury rider covers

Accepted Answer

100% of nonsurgical care rendered within 24-72 hours

Question 38

POS=Point Of Service plan.....

Accepted Answer

allows subscribers to choose between a network provider or an out-of-network provider

Question	Answer
The following are services that BCBS agrees to provide in exchange for provider contracts:	Direct paymetn to PARs, Training sessions for PAR billing staff, Free billing manuals and PAR newsletters, Representative to assist with billing/payment problems, Publishing directory of all PARs
BCBS began as	two prepaid health plans
"Usual, customary and reasonable basis" refers to	the amount commonly charged for a particular medical service by providers within a particular geographic region for establishing their allowable rates.
BCBS fee-for-service is also known as	Traditional coverage
An emergency rider would be necessary to	cover immediate treatment sought and received for sudden, severe, and unexpected conditions that if left untreated would put the patient's health in permanent jeopardy or cause permanent damage o fan organ or body part.
PCP	primary care provider or primary care physician or personal care provider
The Away from Home Care Plan	allows members who are temporarily living outside their HMO service are for at least 90 days to temporarily enroll with a local HMO.
BCBS is a	subscriber-driven program
BCBS indemnity coverage	offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed healthcare provider of their choice.
PPN	preferred provider network , they require providers to adhere to (or follow) managed care provisions
BCBS must allow	conversion from one plan to another when the policy holder moves into an area served by a different BCBS corporation
For-profit commercial plans	have the right to cancel policy at renewal time if the patient is a high user of benefits
The outpatient pretreatment authorization plan (OPAP)	requires preauthorization of physical, occupational and speech therapy services
A non-PAR is allowed to	ask a patient for payment in full on the day of service
AHA	American Hospital Association...they are the approving agency for accreditation of new prepaid hospital plans
Coordinated home health and hospice care are considered	alternatives to acute care setting
Acute respiratory infection or bladder infection are	NOT considered emergency diagnosis
FEHBP	Federal Employee Health Benefits Program
Mandatory second surgical opinion requirement is necessary when a patient when a patient is	considering elective, non emergency surgical care
Mental health benefits are considered a	BCBS major medical benefit
Participating Providers (PARs) agree to write off (adjust) the difference or balance between	between the amount charged by the provider and the approved fee established by the provider (allowed amount)
OPAP deals with	prospective authorization
Riders are special clauses stipulating	additional coverage over and above the standard contract
Indemnity coverage allows	the insured freedom to use any licensed healthcare provider
BCBS corporations conduct	regular training sessions for PAR billing staff
Blue Cross plans began in	1929 and provided coverage for hospital bills
BCBS has to gain approval from their	state insurance commissioners for any rate increases and /or benefit changes
Blue Sheild originated in	1938 and covered physician services
For-profit corporations pay taxes on	profits generated by the corporation's enterprises and pay dividents to shareholders on after-tax profits
When completing secondary claims you should	attach the R.A. (remittance advice)
BCBS includes the following programs:	Fee-for-service, Managed Care Plans, Medicare Supplemental Plans
BCBS claims filing deadline is	one year from the DOS (date of service)
Federal Employee Health Benefits Program issues	insurance identification numbers that begin with the letter "R"
The most common coinsurance amounts range between	20-25%
EPO (Exclusive Provider Organization) is	similar to HMO but more restrictive
Blue Worldwide Expat-	provides medical coverage for employees and dependents who spend more than 6 months outside the U.S.
A special accident injury rider covers	100% of nonsurgical care rendered within 24-72 hours
POS=Point Of Service plan.....	allows subscribers to choose between a network provider or an out-of-network provider

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Chapter 13

insurance