Insurance Basics
Physician seen for routine care
PRIMARY CARE PROVIDER
(PCP)
TPA stands for...
Third Party Administrators
Claim form used by patient and outpatient hospitals
UB-04
UB-92
An electronic system that flags claims in our system that require further review
AUTO-AUDIT
(POS) Where the patient or member’s procedure or visit happened.
Place of Service
A group of healthcare professionals who contract with an insurance provider to offer services at reduced rates.
NETWORK
Our parent company is...
GuideWell
the process of paying claims submitted or denying them
ADJUDICATION
Required by law that employers provide continuation of benefit coverage.
COBRA
Anything that doesn’t require overnight hospitalization.
Outpatient
The percentage of the costs of medical services paid by the patient.
COINSURANCE
WebTPA President
Dwight Mankin
Claim form used by non-institutional physician and suppliers
HCFA
May show why a claim was denied, approved, paid, as well as what was not paid. Sent to provider.
EOP- Explanation of Payment
Routine health care that includes screenings, check-ups, and patient counseling
Preventive or Wellness
A fee charged each time a person uses their insurance.
COPAYMENT
For questions about benefits, email...
AskHR@bcbsfl.com
Two-digit suffixes added to a code to further distinguish the type of service or procedure being rendered.
MODIFIERS
This section of the grid will give information about the network. Give the number.
Section 2
Fee schedule amounts from networks built into iii:PUT
Fully Loaded
The amount of money a member must pay upfront in order to keep their health insurance policy active.
PREMIUM
Claims processing software that was developed by WebTPA.
iii:Put
Document from a health plan to a provider about a claim payment, explaining how a health plan has adjusted
ERA
Electronic Remittance Advice)
This section of the grid will give pre-certification requirements. Give the number.
Section 11
These are a set of medical codes used describe the procedures and services that are performed.
CPT Codes