B&C Chapter 13: BlueCross BlueShield Flashcards
Away From Home Care
provides continuous BCBS health care coverage for subscribers who will be located outside of their home service area for more than 90 consecutive days; subscribers are permitted access to participating providers in other areas of the United States.
BCBS basic coverage
BlueCross BlueShield (BCBS) coverage for the following services: hospitalization, diagnostic laboratory services, x-rays, surgical fees, assistant surgeon fees, obstetric care, intensive care, newborn care, and chemotherapy for cancer.
BCBS major medical (MM) coverage
provides patients with nationwide access to participating providers who offer a wide variety of health care services; reasonable out-of-pocket expenses, such as deductibles and coinsurance payments are included.
BlueCard
program that allows BCBS subscribers to receive local Blue Plan health care benefits while traveling or living outside of their plan’s area.
BlueCare Anywhere
allows members to have telehealth access to health care benefits for a number of non-urgent illnesses and injuries.
BlueCross BlueShield (BCBS)
provides health plan coverage to Americans in all 50 states, the District of Columbia, and Puerto Rico; coverage is also provided to those who live, travel, and work internationally.
BlueCross BlueShield Association (BCBSA)
independent, community-based, locally operated BlueCross BlueShield plans that collectively provide health care coverage to more than 100 million Americans.
BlueCross BlueShield Global
international health care coverage for non U.S. based individuals who permanently reside outside the United States and provides health care coverage solutions during short- and long-term travel.
coordinated home health and hospice care
allows patients with this option to elect an alternative to the acute care setting.
Federal Employee Health Benefits Program (FEHBP)
an employer-sponsored health benefits program established by an act of Congress in 1959, which now provides benefits to more than 5 million federal enrollees and dependents.
Federal Employee Program (FEP)
began covering federal employees in 1960, provides benefits to more than 5 million federal enrollees and dependents, and underwritten and administered by participating BlueCross BlueShield plans.
for-profit corporation
pays taxes on profits generated by the corporation’s for-profit enterprises and pays dividends to shareholders on after-tax profits.
GeoBlue
international health care coverage for employers, individuals, and students who are based in the United States and who are short-term travelers and long-term expatriates.
Government-Wide Service Benefit Plan
phrase printed below the BCBS trademark on federal employee plan (FEP) insurance cards, which indicates that the enrollee has federal employer-sponsored health benefits.
Health Care Anywhere
concept that allows members of independently owned and operated health plans to have access to health care benefits throughout the United States and around the world.
indemnity coverage
offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed health care provider.
medical emergency care rider
covers immediate treatment sought and received for sudden, severe, and unexpected conditions that, if not treated, would place the patient’s health in permanent jeopardy or cause permanent impairment or dysfunction of an organ or body party.
member
subscribers
members hospital
hospital that has signed a contract to provide services for special rates.
nonprofit corporation
charitable, educational, civic, or humanitarian organization whose profits are returned to the program of the corporation rather than distributed to shareholders and officers of the corporation.
outpatient pretreatment authorization plan (OPAP)
also called prospective authorization or precertification; requires preauthorization of outpatient physical, occupational, and speech therapy services.
PPN provider
provider who has signed a preferred provider network (PPN) contract and agrees to accept the PPN allowed rate, which is generally 10 percent lower than the PAR allowed rate.
preferred provider network (PPN)
program that requires providers to adhere to managed care provision.
prepaid health plan
contract between employer and health care facility (or physician) where specified medical services were performed for a predetermined fee that was paid on either a monthly or yearly basis.
prospective authorization
see outpatient pretreatment authorization plan (OPAP).
rider
special contract clause stipulating additional coverage above the standard contract.
service location
location where the patient was seen
special accident injury rider
covers 100 percent of nonsurgical care sought and rendered within 24 to 72 hours (varies according to policy) of the accidental injury.
usual, customary, and reasonable (UCR)
description of amount commonly charges for a particular medical service by providers within a particular geographic region; used for establishing allowable rates.
