Medicare Secondary Plan Types
Two ways in which RTB Medicare tab reads for the supplemental Medicare type.
What is
"HCSC Medicare Supplemental product- Medicare part B deductible not covered."
"HCSC Medicare Supplemental product- Medicare part B deductible covered in full."
System that should be used for every benefit inquiry to ensure we are quoting complete and accurate benefit information.
What is Benefit Navigator/Streamline RTB?
Sally, a dependent child, is covered under both her mother's BCBSTX plan and her father's UHC plan. Her mother's DOB is 08/02/1988 and her fathers DOB is 03/19/1991. This plan is primary.
What is UHC?
This information can be located in ACE on the patient card, MPUI Medicare tab, BlueStar Mcare/MSP tab, and RTB patient info tab.
What is Medicare Eligibility Information?
allows the electronic transmission of institutional and professional claims between BCBS plans. The primary objective is to offer BCBS plans the capability of delivering their entire portfolio of healthcare products using a standardized delivery method.
What is BlueCard Program?
four types of Medicare secondary plans offered by HCSC.
What is
Supplemental (Part b covered/not covered)
Standard Carve-Out
Modified Carve-Out
100% COB
Per federal law BCBS cannot require preauthorization or reject a claim for lack of authorization. This applies to a __ hour inpatient stay following vaginal delivery or a __ hour stay following a C-section delivery.
What is 48/96 hrs?
What is BCBSTX?
Written request to the provider or subscriber for the return of funds that our company has overpaid on a claim.
What is a RFCR?
Relays claim information, such as; Billing/Rendering provider information, date of service, services rendered, and pricing allowances that the host plan and the Provider have agreed upon.
What is a SF (Submission Format)?
Determines what BCBS would have paid as primary and then compares what Medicare left as patient responsibility. BCBS then pays the lesser of these amounts.
What is 100% COB?
Indicates if the group allows the normal newborn charges to be billed with mom's.
Hint: Located in RTB
What is RTB normal newborn billing indicator?
John has coverage through his employer under our plan BCBSIL. John is also covered as a dependent spouse through his wife's Aetna plan. This plan is primary.
What is BCBSIL?
Medicare claims with a DOS on or after 04/01/2013 will have a 2% reduction in Medicare payment to the provider. This is due to...
What is Medicare Sequestration?
participates in the BlueCard program by contracting with providers who render medical care to home plan members. Responsible for determining pricing rules and reimbursement to their local providers.
What is the host plan?
RTB Reads:
Calculate eligible dollars, then subtract Medicare's payments and then apply contract deductibles and coinsurance or special major medical calculation (deduct Medicare payment from total charge prior to contract application of payment level).
What is Modified Carve-Out?
Non-invasive lab screening test for colon cancer billed under CPT 81528.
What is Cologuard?
Janet is a Medicare beneficiary. Janet is also covered by a employer retiree plan under BCBSTX. This plan is primary.
What is Medicare?
First step in researching claim denying for IRC 269
What is
Check for Bits on diagnosis and compare to benefit- Pull RTB benefits exactly as the claim is processed. Check for RTB exclusions
If our claim is not priced or there are pricing issues we should...
RTB Reads:
Calculate payable dollars (including all contractual deductible and coinsurance) and the subtract Medicare's payment or use Medicare allowed amount for eligible professional assigned claims.
What is standard Carve-Out method?
Must be reviewed on every benefit call. May provide coverage or vendor information specific to Account/group.
What are RTB Account/Group notes?
James, a dependent child of divorced parents, is covered by his father's BCBSIL plan. He is also covered by his mother's plan through ABC Insurance as well as his step mother's plan through UHC (father has remarried). The divorce decree states that James' father has custody but does not state one parent has primary responsibility for health care expenses. This plan has tertiary liability.
What is ABC Insurance?
a colonoscopy claim can be adjusted to pay at routine level of benefits by adding this modifier to each line of service.
What is modifier 33?
allow plans to communicate with each other by sending messages. This can include Information messages, or a request for medical records
What are message codes?