Terms and Definitions
Coordination of Benefits
Medicare and DSNP 101
Horizon BCBSNJ 101
Grab Bag!!!
100
copayments, deductibles, coinsurance
What is cost share
100
Designed to control the benefits paid to customers who are covered by more than one group health insurance policy. It prevents Horizon BCBSNJ from paying out benefits that exceed covered expenses and duplication of payments.
What is Coordination of Benefits
100
A Federally sponsored program under the Social Security Act that provides hospital benefits, supplementary medical care, and catastrophic coverage to: A) persons 65 years of age and older, and B) some younger persons who are covered by Social Security benefits.
What is Medicare
100
Robert A. Marino
What is Chairman of the Board, President and CEO
100
Protects the privacy and security of an individual’s healthcare information.
What is HIPAA or Privacy?
200
Individually identifiable health information
What is protected health information (PHI)
200
Processes or considers the claim third in a COB situation.
What is teritary insurance?
200
H3154, S5993, H7971, H8298
What are Horizon Blue Cross Blue Shield of NJ Medicare contracts.
200
Newark, NJ
What location is Horizon BCBSNJ's head quarters.
200
medical records, personal records, social security numbers
What is Private Information
300
A request for a review and authoriation for services prior to rendering to determine eligibility under the member's contract
What is Pre Cert
300
If a person has Medicare due to age 65 or a disability (non-ESRD), and he or she or the spouse or domestic partner is actively working, the actively working large group health plan (LGHP) contract is primary over Medicare.
What is Tefra/Defra- Actively working rule.
300
A condition for which patients need dialysis or a kidney transplant.
What is ESRD
300
MLTSS, Medicaid, Horizon NJ TotalCare (HMO SNP), Medicare
What are the 4 components of the Government Programs Division?
300
Home Health Nursing, Radiology, Dialysis, Hearing Services, Durable Medicaid Equipment
What are Ancillary Services
400
A term used to describe additional treatment performed or provided related to patient care, such as lab-work, X-Ray, drugs, DME and anesthesia.
What is Ancillary
400
Individual is age 65 or older and has an employer retirement plan, Medicare pays Primary, retiree coverage pays secondary.
What is Retire Health Plan
400
Must reside in NJ, Not enrolled in Breast Cancer or Cervical Cancer Waiver, Not have ESRD, Not enrolled in a program of all inclusive care for the elderly.
What are the Horizon NJ TotalCare (HMO SNP) requirements?
400
Improving Quality, Access to Care, Cost Efficient
What are the components of the Triple Aim?
400
Sometimes more commonly referred to as E.N.T.s, which stands for "ear, nose, and throat". Entails a combination of surgical skills and office-based medicine and treatment. ENTs cover a lot of issues from sinus problems, allergies, head and neck cancers, and more.
What is an Otolarygologist?
500
When a provider is billing the member for the difference between the amount(s) charges, and the payment(s) made by Horizon NJ TotalCare (HMO SNP).
What is Balance Billing
500
Insurance benefits are paid under the Personal Injury Protection (PIP) or the Extended Medical Benefits (EMB) provision of an automobile policy. It covers the automobile policy holder and the resident relatives of the household. Any situation involving a motor vehicle, regardless whether or not the auto is moving or stationary, or if our member is a passenger, driver or pedestrian, will be considered No Fault.
What is No Fault
500
The member earns an income that is no more than 100% of the Federal Poverty Level and are considered a zero cost share dual eligible member since they are not responsible for paying their Part A or Part B cost sharing. They also are eligible to have full Medicaid benefits.
What is Qualified Medicare Beneficiary Plus (QMB+)?
500
1998
What year did Horizon become Blue Cross Blue Sheild of NJ
500
System made up of ducts, tissues, capillaries, vessels that transport fluid to the circulatory system
What is Lymphatic System
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