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Insurance Term
Billing and coding
| Question | Answer |
|---|---|
| Blue Preferred Plan | Patient receives service at a discounted rate from a panel, or select group of physicians and other health care providers who participate in the program |
| CAREN | computerized telephone inquiry system that provides information about a patient's eligibility, and benefits. |
| C.O.B | program for determining which health insurer pays for services first when a subscriber is covered by more than one health care plan. |
| Contract Number | The alpha numeric combination assigned to the person named on the ID card. 3 character must be included on the for, |
| Copayment | This can be a set dollar amount based on contract benefits, or a percentage of the approved amount that the subscriber pays for medical services. |
| Customary Charge | The charge which the physician or other provider usually charges for specific services |
| Deductible | The amount that must be paid by a subscriber before an insurer begins to pay for medical services. |
| DENIS | Dial in Eligibility Network and Information System- computer based system that gives you access to BCBSM through the internet to obtain information on patient's eligibility, benefits and claim's status. |
| Dependent | person covered by the subscribers health care plan |
| CMS 1500 | Claim form used to report services rendered for payment |
| HMO | Health Maintenance Organization- Patients must choose a PCP who provides services, must obtain referrals to see specialist |
| Master Medical | The coverage that extends and adds benefits to a patient's basic BCBS contract |
| Modifiers | A two character code- either 2 numbers or an alphanumeric code to further clarify information about a CPT code to the insurance carrier |
| NASCO | National Accounts Service Company- reprsents employers such as GM, Ford, and Chrysler to name a few |
| Non-Participating Physician | Physician who has not entered into a written contract to accept BCBS payments as payment in full. Patient would be responsible for the difference in the payment and the physician's charged amount |
| Participating Physician | Physician who has entered into a written contract with BCBS to accept the payment from BCBS as payment in full. Patient can only be charged deductibles, co pay, on non-contract benefit |
| Point of Service (Blue Choice) | Similar to HMO except that subscribers may recieve partial coverage for services not authorized by the PCP |
| PPO (Blue Preferred Plan) | Preferred Provider Organization- patients recieve services at a discounted rate from a select group of physicians and other health care providers who participate in the program. May be co pays` |
| Preauthorization | Process of obtaining approval for a service through the individual's insurance company by establishing that it is medically necessary |
| Pre-existing condition | Medical condition that existed befor a member's BCBS coverage became effective |
| Premium | A dollar amount that is paid for insurance coverage eithe by the insured or by the employer |
| PIN | Unique 10 digit number assigned by BCBS to providers to identify them |
| Subscriber | Person who is enrolled in BCBS for health care coverage. This is the person whose name is listed on the card |
| NPI (National Provider ID) | A unique 10 digit number assigned to providers to ID them on a CMS 1500 claim form. |
Created by:
bossy777
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