Copyright © 2008 Delmar Learning. All rights reserved. Chapter 13 Blue Cross and Blue Shield Plans.

Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 13

Blue Cross

and Blue Shield Plans


2

Introduction

• Blue Cross and Blue Shield – Perhaps the best known plans of medical

insurance in the United States


3

Origin of Blue Cross

• Blue Cross,1929 – Baylor University hospital in Dallas, Texas– Offered teachers in the Dallas school

district a plan of twenty-one days of hospitalization every year for the holder and their dependents in exchange for $6 annual premium


4

Origin of Blue Shield

• “Began as a resolution passed by the House of Delegates at an American Medical Associations meeting in 1938. Resolution supported the concept of voluntary health insurance that would encourage physicians to cooperate with prepaid health care plans.”


5

Joint Ventures

• Blue Cross originally covered only hospital bills – Blue Shield only covered fees for physician

services– Over the years Blue Cross and Blue Shield

have increased their coverage to include almost all health care services


6

BCBS Corporation

• Submit insurance claims for all BCBS subscribers

• Provide access to the Provider Relations Department– Assists PAR provider in resolving claims or

payment problems


7

BCBS Corporation

• Write off the difference or balance between the amount charged by the provider and approved fee established by the insurer

• Bill patients for only the deductible and copay/coinsurance amounts that are based on BCBS-allowed fees


8

BCBS Corporation

• In return, BCBS corporations agree to:– Make direct payments to PARs– Conduct regular training sessions for PAR

billing staff


9

BCBS Corporation

• Provide free billing manuals and PAR newsletters

• Maintain a provider representative department to assist with billing/payment problems

• Publish the name, address, and specialty of all PARs in a directory distributed to BCBS subscribers and PARs


10

Plans

• Blue Cross Blue Shield coverage includes the following programs:– Fee-for-service– Indemnity


11

Plans

• Managed care plans – Coordinated home health and hospice care– Exclusive provider organization – Health maintenance organization – Outpatient pretreatment authorization plan– Point-of-services plan– Preferred provider opinion – Second surgical opinion


12

Plans

• Federal Employee Program

• Medicare supplemental plans

• Healthcare Anywhere


13

Fee-for-Service

• Fee-for-service is selected by two different kinds of people:

– Individuals who do not have access to a group plan

– Small business employers


14

Fee-for-Service

• Those two contracts have two different coverages within one policy:– Basic coverage– Major medical benefits


15

Fee-for-Service

• BCBS basic coverage routinely includes the following services:– Hospitalizations– Diagnostic laboratory services – X-rays– Surgical fees


16

Fee-for-Service

• Assistant surgeon fees

• Obstetric care

• Intensive care

• Newborn care

• Chemotherapy for cancer


17

Fee-for-Service

• BCBS major medical coverage includes the following in addition to the basic: – Office visits – Outpatient nonsurgical treatment– Physical and occupational therapy


18

Fee-for-Service

• Purchase of durable medical equipment

• Mental health visits

• Allergy testing and injections

• Prescription drugs

• Private duty nursing

• Dental care required as a result of a covered accidental injury


19

Billing Notes

• Claims processing: – BCBS plans process their own claims

• Deadline for filing claims: – Customarily once year from the date of

service, unless specified

• Forms used: – Most BCBS currently accept CMS-1500

claim


20

Billing Notes

• Inpatient and outpatient coverage: – Many plans require second surgical

opinions and prior authorization for elective hospitalizations


21

Billing Notes

• Deductible: – Look up in the billing manual or call the

computerized phone bank for eligibility for that patient


22

Billing Notes

• Copayment/Coinsurance: – Most common coinsurance amounts are 20

percent and 25 percent– Some may go as high as 50 percent for

mental health services

• Assignment of benefits:– Payment is made directly to the provider by

BCBS


23

Special Handing

• Make a habit and priority to have a current copy of the front and back of all patient ID cards in the patient’s file

• Patients with Blue Cross who have more then one insurance policy– Must be billed directly to the plan from which

the program originated


24

Special Handing

• NonPARs must bill the patient’s plan for all nonnational account patients with BlueCards

• Rebill claims not paid within 30 days

• Some mental health claims are forwarded to a third-party administrator


25

Primary Claim Status Is Determined When

• Covered by only one BCBS policy

• Covered by both a government-sponsored plan and employer-sponsored BCBS plan

• Covered by a non-BCBS plan that is not employer-sponsored


26

Primary Claim Status Is Determined When

• Designated as the policyholder of one employer-sponsored plan and also listed as a dependent on another employer-sponsored plan.


27

Secondary Coverage

• Modifications are made to the CMS-1500 claim when patients are covered by primary and secondary or supplemental health plans.


28

When Completing BCBS CMS-1500 Claims

• Block 12- Enter signature on file

• Block 19- Leave Blank

• Block 20- Enter an X in the NO box

• Block 23- Leave blank


29

When CompletingBCBS CMS-1500 Claims

• Block 26- Enter the patient’s account number

• Block 27- Enter an X in the YES box

• Block 31- Enter the provider’s complete name with credentials

Copyright © 2008 Delmar Learning. All rights reserved. Chapter 13 Blue Cross and Blue Shield Plans.

Documents

delmar learning

blue shield plans

years blue cross

introduction blue cross

origin of blue shield

service indemnity slide

surgical opinion slide

joint ventures blue