Chapter 12 Blue Cross Blue Shield

Question 1

Blue Cross Blue Shield

Answer 1

Blue Cross Blue Shield (BCBS) is a nationwide system of independent and locally operated companies, offering a variety of health insurance products including group and individual policies. BCBS has partnered with the federal government to process Medicare fee-for-service claims.

Question 2

The BCBS Federal Employee Program (FEP) covers more than 5.5 million federal government employees, dependents, and retirees.

Answer 2

Nationwide, the Blues plans have more than 1.7 million doctors and hospitals contracted with Blue Cross Blue Shield companies — more than any other insurer. More than 96 percent of hospitals and 95 percent of professional providers’ contract with Blue Cross Blue Shield companies.

Question 3

Common Types of Insurance Plans

Answer 3

Blue Cross Blue Shield offers a wide variety of insurance plans

Question 4

Health Maintenance Organization (HMO)—

Answer 4

A type of health benefits plan where members are required to receive healthcare only from providers that are part of the HMO network.

Question 5

Medicare

Answer 5

Blue Cross Blue Shield offers a Medicare Advantage plan - a federally funded health insurance, typically for those aged 65 and over, or for people under 65 who are disabled or meet other special criteria.

Question 6

Preferred Provider Organization (PPO)

Answer 6

A plan that allows members to choose any provider but offers higher levels of coverage

Question 7

Indemnity

Answer 7

Also known as traditional insurance or fee-for-service.

Question 8

Point of Service (POS)

Answer 8

Point-of-Service coverage is a healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross Blue Shield network or seek medical care outside of the network.

Question 9

Medicaid—

Answer 9

A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

Question 10

Flexible Spending Accounts (FSA

Answer 10

The funding for FSAs is usually through deductions from the employee’s paychecks.

Question 11

Health Savings Account (HSA) pretax (deducted from your paycheck)

Answer 11

An account that reimburses employees for specific healthcare expenses.

Question 12

Blue Cross Blue Shield Member Card

Answer 12

Plan

SUB

Medical Network

ID number

Group number

Rx Group number

Copay

Question 13

Billing TIP

Answer 13

Obtaining a copy of an insurance card, front and back, is imperative. If the information is entered into the practice management system incorrectly or additional information is needed, it can be found on the insurance card.

BCBS of Texas reiterates the importance of obtaining a copy of the insurance card with the following claims filing tips:

Obtain a copy of the member’s current insurance card at all visits, as policies can often change. This will ensure that the claims are submitted with the most current policy information.
Verify the correct alpha prefix is on all claims - this is extremely important. Many claims cannot be processed without the member’s alpha prefix.

Question 14

Contractual Requirements

Answer 14

A participating provider is a healthcare provider, hospital, or entity that has agreed to provide healthcare services to an insurance plan’s enrollees.

Question 15

Contractual Requirements

Answer 15

Credentialing is the process which BCBS reviews and validates the professional qualifications of healthcare providers who apply for participation with the organization.

Question 16

Contractual Requirements

Answer 16

Participating providers sign contracts with the insurance companies they wish to participate with and agree to accept the fee schedules set by the insurance company.

Question 17

Contractual Requirements

Answer 17

The physician then can only bill the patient for their deductible, copay, coinsurance, and any non-covered services. They cannot balance bill the patient the difference between what the company allowed and what the physician billed.

Question 18

Contractual Requirements

Answer 18

BCBS was one of the first companies to use this model and other insurance companies later followed their lead. This idea is a proven way to keep costs down

Question 19

Provider Manuals

Answer 19

Policies for BCBS carriers will vary from state to state and plan to plan. Information vital to providers is often found in the provider manual.

Question 20

Section Review 12.1

Which of the following defines Point-of-Service coverage?

Don’t confuse with POS Place of Service

Answer 20

Answer: C. Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network.

Question 21

An indemnity plan is also referred to as _____________.

Answer 21

Answer: A. Fee-for-Service

Question 22

When a provider signs a contract to be a participating provider with an insurance payer they are agreeing to:

Answer 22

Answer: C. Accept the fee schedules set by the insurance company.

Question 23

Which of the following is an account that is usually funded by the employee only and reimburses employees for specified expenses as they are incurred?

Answer 23

Answer: C. FSA

HSA: Funding for HSAs can be by the BCBS company member, an employer, or anyone else.

Question 24

Which type of insurance plan is a federal and state program that provides coverage to the low-income population?

Answer 24

Answer: C. Medicaid

Question 25

Claims Filing Requirements

Answer 25

*Timely filing of claims is a time frame outlined in the Provider Participation Agreement.

*This requirement states that a claim needs to be submitted to the insurance payer within a specified amount of time.

*Each insurance company sets their own timely filing limits. It can also vary by different insurance plans within the same company.

Question 26

EXAMPLE

BCBS North Carolina (NC) Federal Employee Program (FEP) requires claims to be filed by December 31 of the calendar year while BCBS NC BlueCard claims must be filed within 180 days of the date of service according to the policies stated below from the BCBS NC Provider eManual.

Answer 26

Timely Filing Requirements (FEP)

Providers participating with BCBSNC are required to file FEP claims by December 31 of the calendar year

Question 27

Timely Filing

Claims for professional services provided to BlueCard® members having coverage with other Blue Plans (non-BCBSNC) must be submitted to BCBSNC within 180 days of providing service.

Answer 27

Source: https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/2020_commercial_bluebook.pdf

Question 28

Explanation of Benefits (EOB)

Answer 28

To explain the status of a claim, Blue Cross Blue Shield sends an Explanation of Benefits (EOB) to their covered members,

*and a Remittance Advice (RA) to providers after they or other covered family members receive healthcare services.

*BCBS encourages the use of electronic funds transfer (EFT) and electronic remittance advice (ERA).

Question 29

Common Denials

Answer 29

*Incorrect member alpha-prefix and ID number or member not covered

*Duplicate claim. Automatically resubmitting claims that have not been paid or denied slows down the claims payment process and creates confusion for the member who will receive multiple EOBs

*Automatically resubmitting claims that have not been paid or denied slows down the claims payment process and creates confusion for the member who will receive multiple EOBs

*Claim filed after the timely filing limit

*Incorrect provider number (NPI rejections)

*Missing, incorrect, or invalid modifier

*Missing or incorrect quantity billed—

Question 30

Non-compliance with coverage policy errors:

Answer 30

*Prior Authorization

*Coverage Terminated

*Missing Referral

*Medical necessity errors - the service or procedure was not medically necessary. If a claim is denied due to medical necessity, the medical record should be reviewed to determine if the documented diagnosis was submitted correctly.

Question 31

Insurance Representative

Answer 31

An Insurance Representative, also called Provider Representative or Provider Network Consultant, serves as the liaison between Blue Cross Blue Shield and the contracted provider community. The representative keeps the providers up-to-date on products, programs and initiatives, training opportunities, and contractual compliance.

Question 32

BILLING TIP

Answer 32

Forming a good relationship with the insurance Provider Representative has many benefits. They can assist a provider if they are having billing issues, contracting issues, etc.

Question 33

Appeals

Answer 33

Each BCBS carrier will have their own appeals process. The appeals process is typically outlined in the BCBS provider manual.

Question 34

Section Review 12.2

Which of the following statements is NOT correct regarding timely filing?

Answer 34

Answer: C. If the physician fails to send a claim during the timely filing limit, the balance can be sent to the patient.

Question 35

What is the timely filing requirement for Blue Cross Blue Shield?

Answer 35

Answer: D. Claim requirements differ between plans

Question 36

What is the correct action when the three-character prefix is not appended to a BCBS identification number?

Answer 36

Answer: D. Look at the patient’s BCBS card and append the appropriate prefix listed on the card.

Question 37

What is the correct action when a claim has been submitted to BCBS but the provider has not received a response?

Answer 37

Answer: B. Check claim status with the local BCBS carrier.

Question 38

Point of Service (POS)—

it’s not the same as POS: Place of Service.

Answer 38

Point-of-Service coverage is a healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross Blue Shield network or seek medical care outside of the network.