Private Insurance
Major Private Payers/ Bluecross/shield Association
Billing Guideline
Private Payer Claims/ Capitation Management
100
What covers more than 8 million federal employees, retirees, and their families?
Employees Health Benefits programs.
100
What is a licensing agency of BCBS plans?
BlueCross BlueShield Association.
100
What are the main parts of participation contract?
Introductory section. Contract purpose and covered medical services. Physicians responsibilities. Managed care plan obligations. Compensation and billing guidelines.
100
Define monthly enrollment list
What is document of eligible members of a capitated plan for a monthly period?
200
What is 7 steps?
*How many steps are in the medical billing cycle*
200
What is an insurance company's agreement to reimburse a policyholder a predetermined amount for covered losses?
Indemnity plan.
200
What are types of services that the provider must offer to plan members?
What are covered services.
200
What do typical contracts with a primary care provider usually provide?
Preventive care Counseling and telephone calls Office visits Medical care Local treatment of first degree burns, application of dressings, etc.
300
What is the definition of rider?
A Document modifying an insurance contract.
300
Name three things that subscriber identification cards list.
Plan name, type of plan, and subscriber identification number.
300
Define utilization review
What is payer's process for determining medical necessity.
300
Under a capitated contract, providers bill patients for services not covered by ____.
What is cap rate.
400
What is an organization that pays for health insurance directly and sets up a fund which to pay?
What is self-insured health plan.
400
What is Periodic verification that a provider or facility meets professional standards?
Credentialing
400
What are primary and secondary plans?
Another variable in collecting co-payment.
400
Most HMOS require capitated providers to submit _________ for patients encounters.
What is encounter reports.
500
What is a monetary amount after which benefits ends AKA maximum benefit limit?
Lifetime limit
500
Private payers supply complete insurance service, such as
Contracting with employers and with individuals to provide insurance benefits. Setting up physician, hospital, and pharmacy networks. Establishing fees. Processing claims Managing the insurance risk.
500
Define elective surgery
What is a nonemergency surgical procedure?
500
What is guidelines to general claims for CMS-1500 form follow?
Example the NUCC guidelines
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