Acronyms
CBC
Capital Blue Cross
A provider who has a contract with the insurance company and who will accept the Allowed Amount as Payment in full.
INN Provider
It requires medical coverage be provided for a member's newborn child for a period of 31 days starting from the infant's birth date. Thirty-one days of coverage are provided even if the child is not added to the contract.
Act 81 Newborn
200 Name 1 other Blue plan in PA
Highmark or Independence Blue Cross
Do PPO plans require referrals?
No
What are crayons made of?
Wax
ACA
Affordable Care Act
A specified dollar amount of eligible expenses for covered services that must be incurred by the member before the Plan assumes liability for all or part of the remaining expense for covered services.
Deductible
This is a Pennsylvania state mandate that requires CBC to cover a minimum 48-hour inpatient stay following a normal delivery and a minimum 96-hour inpatient stay following a cesarean section.
Act 85—Maternity
T or F, Trucare handles our muscuskeletal auths
False, it is Turning Point
Name 1 type of plan that does not have OON benefits
HMO and EPO
T or F, some cats are allergic to humans
True
DF
Disposition Format
A dollar limit for cost-sharing amounts incurred by a member for covered services in a benefit period. When the OOP limit is reached, the member is not subject to any more cost-sharing for the rest of the benefit period.
Out-of-Pocket
It requires CBC to reimburse a member or provider for medically necessary emergency services.
Act 112 of 1996 (Emergency Services)
Under the ACA at what age do dependents roll off of their parent’s plan?
26
What Plan uses capitation as payment?
HMO
What is the national Animal of Scotland?
Unicorn
MTM
Member Touchpoint Measures
Determine the authorized allowance on a claim according to benefits available under a specific contract.
Adjudicate
It requires CBC to provide colorectal cancer screening coverage in accordance with the ACS guidelines for such screenings.
Act 62 of 2008
What is our plan code?
361
What is CHIP?
Children’s Health insurance program
What animal sleeps with 1 eye open?
Dolphin
HSA
Health Saving Account
This is sent to a member and it shows how a claim is processed. A “receipt” of how the claim was processed. It will show them the charge of the service/s, how much CBC “allowed” for the service, how much CBC paid for the service, and how much they are responsible for
EOB, explanation of benefits
It allows full time students, whose studies were interrupted by National Guard or armed forces reserve duty, to extend health care benefits until they finish school, regardless of age
Act 83 of 2005 (Soldiers Returning from Deployment)
How many BCBS plans are there?
35
T or F, By law all Medical plans MUST have a minimum deductible
False
BONUS 1000 Pts!!!!
KHP
Keystone Health Plan
A clinical management program established to prospectively review and evaluate requests for services to determine whether they are medically necessary and appropriate.
Preauth
It prohibits discrimination on the basis of genetic information with respect to health insurance and employment
Genetic Information Nondiscrimination Act (GINA)
Is POS 55 inpatient or outpatient?
Inpatient
What type of plan does NOT have a set copay?
High deductible health plan HDHP
How many pleats does a chef’s hat have?
100
HME
Home Medical Equipment
The process of correcting a claim payment amount and submitting a revised claim payment record to a provider or member showing the new amount paid
Adjustment
1400 Group health plans are required to provide coverage for the diagnostic assessment and treatment of autism spectrum disorders to members under 21 years of age. This includes any pervasive development disorders such as Asperger's Syndrome
Act 62 of 2008 (Autism Spectrum Disorder)
Who is our CEO?
Todd Shamash
What is Medicare Part B?
Covers Professional/ Dr claims
60% of the human brain is made of what?
Fat
MAC
Maximum Allowable Charge
A program developed by the BCBSA that utilizes the ITS to ensure that all claims for BC/BS members are processed in a consistent manner.
Bluecard
This is a state mandate requiring CBC provide coverage to members who are under 21 years of age for specific childhood immunizations.
Act 35 of 1992 (Childhood Immunizations)
Who administers the MTM program?
BCBSA , Blue Cross Blue Shield association
If you have an EPO plan can you see a PPO doctor and receive INN benefits?
Yes
What state banned banning clotheslines?
Vermont
NCAS
National Claims Administrative Services
Provisions and procedures used by insurers or third party payers to avoid duplicate payment for losses covered under more than one policy or contract.
COB
This law requires parity between oral chemotherapy medications and intravenously administered or injected chemotherapy medications
Oral Chemotherapy Medications Mandate
What is a Perinatologist?
doctors who handle high-risk pregnancies.
Name 2 services eligible under Major Medical:
Office visits for sickness or injury,Facility/professional clinic visits, Injections, Non-self-administered drugs
Home medical equipment (DME)
Infusion/IV therapy when billed by a facility in an Outpatient setting Note.
Outpatient psychiatric
Ambulance
Non-participating balances
Physical therapy
Orthotics and prosthetics
Dental accidents
Non-participating Freestanding Diagnostic Facility
Spinal manipulations
What does M&M stand for?
Mars and Murrie
BSBS
Benefit Summary Benefit Standard
The process by which a health plan signs up groups and individuals for membership, or the total number of enrollees who sign up in any one group
This is a Pennsylvania state mandate.
It allows for medication synchronization, "Med Sync," for patients taking two or more maintenance medications.
Act 46 of 2019 (Med Sync)
What plan (state) did sccf 13120213063864100 come from?
131,Anthem
What are 2 of the 3 ways to obtain insurance?
Employer
Directly from the insurance company
Government (Medicare)
What was the profession of the man that invented speed dating?
Rabbi