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

2. Copyright © 2008 Delmar Learning. All rights reserved. 2 Introduction Blue Cross and Blue Shield –Perhaps the best known plans of medical insurance in the United States

3. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 8 BCBS Corporation In return, BCBS corporations agree to: –Make direct payments to PARs –Conduct regular training sessions for PAR billing staff

9. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 10 Plans Blue Cross Blue Shield coverage includes the following programs: –Fee-for-service –Indemnity

11. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 12 Plans Federal Employee Program Medicare supplemental plans Healthcare Anywhere

13. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 14 Fee-for-Service Those two contracts have two different coverages within one policy: –Basic coverage –Major medical benefits

15. Copyright © 2008 Delmar Learning. All rights reserved. 15 Fee-for-Service BCBS basic coverage routinely includes the following services: –Hospitalizations –Diagnostic laboratory services –X-rays –Surgical fees

16. Copyright © 2008 Delmar Learning. All rights reserved. 16 Fee-for-Service Assistant surgeon fees Obstetric care Intensive care Newborn care Chemotherapy for cancer

17. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 20 Billing Notes Inpatient and outpatient coverage: –Many plans require second surgical opinions and prior authorization for elective hospitalizations

21. Copyright © 2008 Delmar Learning. All rights reserved. 21 Billing Notes Deductible: –Look up in the billing manual or call the computerized phone bank for eligibility for that patient

22. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 27 Secondary Coverage Modifications are made to the CMS-1500 claim when patients are covered by primary and secondary or supplemental health plans.

28. Copyright © 2008 Delmar Learning. All rights reserved. 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. Copyright © 2008 Delmar Learning. All rights reserved. 29 When Completing BCBS 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