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Health Insurance today Chapter 11,

A well defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment observation care
This occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department direct admission
Usually covers the deductible and copay or coinsurance of a primary health insurance policy supplemental plan
The legal business name of the practice billing entity
Supplemental plans designed by the federal government but sold by private commercial insurancies companies to "cover the gaps in Medicare" medigap
An employee sponsored health benefits program established by an act of congress in 1959 federal employee health benefits program (FEHBP)
This enables such members obtaining healthcare services while traveling or living in another BCBS plan's service area to reveive benefits oftheir home plan contract and to access local provider networks bluecard program
Special clauses stipulating additional coverage over and above the standard contract riders
Offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed health care provider idemnity coverage
The amount commonly charged for a particular medical service by providers within a particular geographic region for establishing their allowable rates usual, customary,and reasonable (UCR)
HIPAA privacy standards require providers to notify patients about their right to privacy
Development of an insurance claim begins when the: patient contacts the provider's office and schedules an appointment
When a fee submitted to an insurance company is higher than the health care provider's normal fee for the coded procedure,the provider must: attach a letter to the claim explaining the rationale for the higher charge
Optical character reader (OCR) guidelines were established when the : CMS 1500 claim form was developed
When typewritten data is CMS-1500 claim form runs over into adjacent blocks, the claim will be: rejected and returned to the provider
Which is the proper way to prepare a rejected claim for resubmission? create the corrected claim on an original (red-print) claim form
Remittance advice forms that are organized and filed according to month and payer are: open assigned cases
Another term that can be used to indicate a fee-for-service plan is a ____________ plan noncapitated
Benefits such as coverage for copayments, deductibles, and coinsurance are offered by which type of insurance plan? supplemental
Proir to the joint venture between Blue Cross and Blue Shield, the Blue Shield plans covered only: physician services
Blue Cross facilities that had signed contracts to provide services to subscribers for special rates were known as_______hospitals member
Which is the function of the BlueCross BlueShield Association(BCBSA) national advertising
The preferred provider network (PPN) allowed rate is generally: 10 percent lower than the participating provider rate
Small businesses are likely to select which BCBS coverage? fee-for-service
What is an example of a benefit covered by BCBS basic coverage? assistant surgeon fees
What BCBS plan type offers the most flexibility for subscribers? indemnity coverage
The outpatient pretreatment authorization plan (OPAP) is also known as: precertification
What title is listed on the BCBS identification cards for federal employees? government-wide service benefit plan
BCBS Medicare supplemental plans are also known as? medigap
Which is a program that requires providers to adhere to managed care provisions preferred provider network
One of the expectations that nonparticipating provider has is to_____for services rendered: obtain payment for the full fee charged
Which is considered a minimum benefit under BCBS basic coverage? hospitalizations
Which is considered a service reimbursed by BCBS major medical coverage? mental health visits
Which is a special clause in an insurance contract that stipulates additional coverage over and over and above the standard contract? rider
Prospective authorization or precertification is a requirement of the_____BCBS managed care plan outpatient pretreatment authorization
Created by: kduvall20