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Terms & Definitions
Claim Forms
Claims Coding
Stop Payments/Pay and Educate
Miscellaneous
100
The fixed dollar amount that is due and payable by the member at the time the service is provided.
What is copay?
100
This claim form is used to file professional claims.
What is CMS-1500?
100
A three to five digit code that indicates why the service is being performed.
What is diagnosis code?
100
This displays in the Check Status field to indicate that a check has not yet been cashed?
What is Open
100
A North Carolina mandate that states BCBSNC has 30 calendar days to pay, deny or request additional info after the receipt of a claim
What is Prompt Pay?
200
Money, for covered services, that must be paid by the insured before an insurer will assume any liability for all or part of the remaining cost of covered services.
What is deductible?
200
This claim form is used to file institutional claims.
What is UB-04?
200
A five digit code that indicates what service is being performed.
What is CPT code (procedure code)?
200
A Pay and Educate decision is a anytime exception to a previously adjudicated claim which was not favorable to the Member.
What is False (A Pay and Educate decision is a one-time exception to a previously adjudicated claim which was not favorable to the Member.)
200
A Coordination of Benefits rule that states that the policy of the parent whose birthday comes first during the year is the primary policy
What is the birthday rule?
300
A claim that has been reversed and reprocessed
What is Adjusted Claim?
300
***DAILY DOUBLE*** The code used on a UB-04 to indicate the type of facility, bill classification, and frequency.
What is Bill Type?
300
Ancillary providers file claims using this type of procedure code.
What is HCPCS Code
300
This is the 3rd step to the Pay and Educate Process.
What is to determine whether the member is eligible for the one-time exception
300
Blue e is an Internet-based application for provider enrollment and financial management. Blue Cross and Blue Shield of North Carolina (BCBSNC) provides this service to providers free of charge.
What is False Providers do not use Blue E for Provider Enrollment. Blue E is used to check provider payments, member eligibility, rebundling rules and member's benefits.
400
A list of predetermined payment rates for medical services agreed to by a provider or provider network and the insurance company
What is Fee Schedule?
400
The field on a CMS-1500 form that must be filled in by the provider to indicate a corrected claim.
What is Box 22?
400
***DAILY DOUBLE*** Diagnosis codes for routine/preventive servces generally begin with this
What is the letter "V"?
400
2 reasons a stop payment and reissue request can be processed before the 30 day waiting period include:
What are: *Check was stolen *Check was endorsed and lost *Check was totally destroyed (If torn or damaged, recipient will need to return it to Financial Processing Services with a note requesting reissue - See mailing address below) *Payee has a valid reason for immediate void and reissue of check (determined on a case-by-case basis)
400
Members must take these steps in the event of an emergency.
What is 1. seek help/care immediatly from an emergency room or other similar facilities. 2. If necessary, call 911 or use other community emergency resources to obtain assistance 3. If unsure whether a condition is an emergency, call Healthline Blue
500
A contract provision whereby providers agree not to charge members more than the allowable charges for covered services.
What is Hold Harmless?
500
The three types of paper claims.
What is CMS-1500 (Professional), UB-04(Facility), and Subscriber/Member?
500
In a diagnosis code, the two digits after the decimal indicate this.
What is severity?
500
If a CSP offers a Pay and Educate for a Pediatric dental claim in FACETS, this subject and category should be selected before pending the task.
What is Subject: Dental Claims, and the Category: PAY AND EDUCATE^.
500
Calculate BCBSNC and member liability in the following scenario: $1000 benefit deductible $500 deductible met 70/30 coinsurance $1500 billed charges $925 allowed amount
What is $297.50 (BCBSNC pays) & $627.50 (Member pays)