insurance
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| 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
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| BCBS began as | two prepaid health plans
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| "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.
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| BCBS fee-for-service is also known as | Traditional coverage
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| 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.
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| PCP | primary care provider or primary care physician or personal care provider
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| 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.
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| BCBS is a | subscriber-driven program
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| 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.
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| PPN | preferred provider network , they require providers to adhere to (or follow) managed care provisions
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| BCBS must allow | conversion from one plan to another when the policy holder moves into an area served by a different BCBS corporation
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| For-profit commercial plans | have the right to cancel policy at renewal time if the patient is a high user of benefits
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| The outpatient pretreatment authorization plan (OPAP) | requires preauthorization of physical, occupational and speech therapy services
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| A non-PAR is allowed to | ask a patient for payment in full on the day of service
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| AHA | American Hospital Association...they are the approving agency for accreditation of new prepaid hospital plans
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| Coordinated home health and hospice care are considered | alternatives to acute care setting
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| Acute respiratory infection or bladder infection are | NOT considered emergency diagnosis
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| FEHBP | Federal Employee Health Benefits Program
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| Mandatory second surgical opinion requirement is necessary when a patient when a patient is | considering elective, non emergency surgical care
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| Mental health benefits are considered a | BCBS major medical benefit
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| 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)
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| OPAP deals with | prospective authorization
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| Riders are special clauses stipulating | additional coverage over and above the standard contract
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| Indemnity coverage allows | the insured freedom to use any licensed healthcare provider
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| BCBS corporations conduct | regular training sessions for PAR billing staff
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| Blue Cross plans began in | 1929 and provided coverage for hospital bills
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| BCBS has to gain approval from their | state insurance commissioners for any rate increases and /or benefit changes
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| Blue Sheild originated in | 1938 and covered physician services
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| For-profit corporations pay taxes on | profits generated by the corporation's enterprises and pay dividents to shareholders on after-tax profits
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| When completing secondary claims you should | attach the R.A. (remittance advice)
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| BCBS includes the following programs: | Fee-for-service,
Managed Care Plans,
Medicare Supplemental Plans
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| BCBS claims filing deadline is | one year from the DOS (date of service)
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| Federal Employee Health Benefits Program issues | insurance identification numbers that begin with the letter "R"
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| The most common coinsurance amounts range between | 20-25%
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| EPO (Exclusive Provider Organization) is | similar to HMO but more restrictive
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| Blue Worldwide Expat- | provides medical coverage for employees and dependents who spend more than 6 months outside the U.S.
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| A special accident injury rider covers | 100% of nonsurgical care rendered within 24-72 hours
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| POS=Point Of Service plan..... | allows subscribers to choose between a network provider or an out-of-network provider
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