Blue Cross 101

An
An Introduction
Introduction to
to Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama
Welcome

Welcome to Blue Cross 101!

Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama designed
designed this
this course
course to
to give
give you
you aa brief
brief
overview
overview ofof who
who we
we are
are and
and how
how we
we operate.
operate. Included
Included in
in the
the course
course are
are key
key
contacts,
contacts, aa glossary
glossary of
of terms
terms and
and every
every day
day information
information aa provider’s
provider’s office
office needs
needs
to
to know.
know.
History
Hospital Service Corporation – 1936
In
In 1936
1936 aa special
special act
act of
of the
the Alabama
Alabama legislature
legislature made
made itit possible
possible for
for the
the
“Hospital
“Hospital Services
Services Corporation
Corporation of of Alabama”
Alabama” toto open
open for
for business
business and
and sell
sell
hospital
hospital insurance.
insurance. AtAt that
that time,
time, the
the organization
organization employed
employed only
only six
six people.
people.
We
We now
now have
have over
over 4,000
4,000 associates.
associates. There
There were
were nono ID
ID cards,
cards, members
members
simply showed their last receipt of payment as proof of
simply showed their last receipt of payment as proof of insurance.insurance.
History
Hospital Service Corporation – 1936
In
In 1936
1936 aa special
special act
act of
of the
the Alabama
Alabama legislature
legislature made
made itit possible
possible for
for the
the
“Hospital
“Hospital Services
Services Corporation
Corporation of of Alabama”
Alabama” toto open
open for
for business
business and
and sell
sell
hospital
hospital insurance.
insurance. AtAt that
that time,
time, the
the organization
organization employed
employed only
only six
six people.
people.
We
We now
now have
have over
over 4,000
4,000 associates.
associates. There
There were
were nono ID
ID cards,
cards, members
members
simply showed their last receipt of payment as proof of
simply showed their last receipt of payment as proof of insurance.insurance.

Blue Cross and Blue Shield of Alabama – 1952

In
In 1952,
1952, the
the Hospital
Hospital Services
Services Corporation
Corporation of
of Alabama
Alabama changed
changed its
its name
name to
to
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama and
and began
began to
to provide
provide insurance
insurance for
for
hospital and professional services.
hospital and professional services.
History
Hospital Service Corporation – 1936
In
In 1936
1936 aa special
special act
act of
of the
the Alabama
Alabama legislature
legislature made
made itit possible
possible for
for the
the
“Hospital
“Hospital Services
Services Corporation
Corporation of of Alabama”
Alabama” toto open
open for
for business
business and
and sell
sell
hospital
hospital insurance.
insurance. AtAt that
that time,
time, the
the organization
organization employed
employed only
only six
six people.
people.
We
We now
now have
have over
over 4,000
4,000 associates.
associates. There
There were
were nono ID
ID cards,
cards, members
members
simply showed their last receipt of payment as proof of
simply showed their last receipt of payment as proof of insurance.insurance.

Blue Cross and Blue Shield of Alabama – 1952

In
In 1952,
1952, the
the Hospital
Hospital Services
Services Corporation
Corporation of
of Alabama
Alabama changed
changed its
its name
name to
to
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama and
and began
began to
to provide
provide insurance
insurance for
for
hospital and professional services.
hospital and professional services.

Preferred Medical Doctor (PMD) – 1984

In
In 1984,
1984, Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama introduced
introduced the
the Preferred
Preferred
Medical
Medical Doctors
Doctors (PMD)
(PMD) network.
network. This
This network
network hashas grown
grown to
to become
become the
the
largest
largest Preferred
Preferred Provider
Provider Organization
Organization (PPO)
(PPO) in
in Alabama
Alabama and
and one
one of
of the
the
largest
largest preferred
preferred provider
provider networks
networks in
in the
the county.
county.
Who Are We?
Since
Since 1936,
1936, Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama’s
Alabama’s goal
goal has
has remained
remained the
the same.
same.
“Provide
“Provide access
access to
to quality
quality health
health care
care in
in aa caring
caring manner.”
manner.”
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama isis aa not-for-profit
not-for-profit organization
organization which
which means
means that
that
we
we are
are not
not aa stock
stock company
company andand we
we do
do not
not sell
sell pieces
pieces of
of the
the company
company in
in financial
financial
markets.
markets. We have a Board of Directors that consists of Alabama residents, physicians,
We have a Board of Directors that consists of Alabama residents, physicians,
hospitals administrators and business leaders.
hospitals administrators and business leaders.

Remaining
Remaining aa not-for-profit
not-for-profit plan
plan allows
allows Blue
Blue Cross
Cross to
to maintain
maintain one
one of
of the
the lowest
lowest
administrative
administrative expense
expense ratios
ratios in
in the
the nation.
nation. For
For every
every $1
$1 that
that aa subscriber
subscriber pays
pays
toward health insurance, less than $.06 goes to administrative expenses.
toward health insurance, less than $.06 goes to administrative expenses.

Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama is
is an
an independent
independent member
member ofof the
the Blue
Blue Cross
Cross and
and
Blue Shield Association located in Chicago, Illinois. There are approximately 38 member
Blue Shield Association located in Chicago, Illinois. There are approximately 38 member
Plans
Plans across
across the
the country.
country.
Who Are Our Members?
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama provides
provides coverage
coverage for
for Self-Insured
Self-Insured
groups
groups and
and Underwritten
Underwritten groups.
groups. Here
Here is
is an
an explanation
explanation of
of each
each type
type of
of group:
group:

Self-Insured
Self-Insured or or Self-Funded
Self-Funded Groups
Groups
Self-Insured
Self-Insured or
or Self-Funded
Self-Funded members
members account
account for
for 60-70
60-70 percent
percent of
of our
our
groups.
groups. These groups determine their own benefit structure and pay for
These groups determine their own benefit structure and pay for
their
their own
own claims.
claims.

Underwritten
Underwritten Groups
Groups
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama assumes
assumes the
the financial
financial risk
risk for
for these
these
groups, determines benefit structures and pays claims out of premiums
groups, determines benefit structures and pays claims out of premiums
collected
collected from
from the
the group.
group.
Communication
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama knows
knows thethe importance
importance ofof communication
communication with with our
our provider
provider
community.
community. Although
Although we we use
use several
several methods
methods of of communication,
communication, the the Internet
Internet is
is our
our most
most valuable
valuable
communication
communication tool.
tool. Our
Our web
web site
site provides
provides Hot
Hot Topics,
Topics, newsletters,
newsletters, meeting
meeting registrations,
registrations, manuals,
manuals,
medical
medical policies,
policies, fee
fee schedules,
schedules, forms,
forms, prescription
prescription drug
drug guides,
guides, etc.
etc. Once
Once new
new information
information is is
added
added to the web site, an e-mail notification is sent to alert providers. Therefore, it is critical that
to the web site, an e-mail notification is sent to alert providers. Therefore, it is critical that
we
we have
have accurate
accurate e-mail
e-mail addresses
addresses forfor your
your office.
office. Please
Please e-mail
e-mail Blue
Blue Cross
Cross at
at
provider_notify@bcbsal.org
provider_notify@bcbsal.org and and include
include your
your e-mail
e-mail address,
address, provider
provider identification
identification number
number
and
and aa contact
contact person.
person.

The
The following
following page
page contains
contains instructions
instructions to
to help
help you
you locate
locate this
this important
important information.
information.

www.bcbsal.com
www.bcbsal.com

Once you have chosen

“I am a provider,” an entire
page dedicated to provider
notifications, education,
forms, patient eligibility and
benefits, medical policies,
and much more is available.
Provider Mailings
Blue Cross and Blue Shield of Alabama continues to mail our newsletters to
providers that do not have access to the Internet. The ProviderFacts and
Special Bulletins are our most commonly known newsletters. Make sure
that Blue Cross has your correct mailing address. If you need to make a
correction to your address, please notify our Provider Data department.

To receive these newsletters and much more in the

fastest manner possible, access our web site,
www.bcbsal.com, under Provider Resources.
Provider Customer Service
Our
Our motto
motto is
is to
to provide
provide exceptional,
exceptional, personalized
personalized service
service to
to our
our customers
customers every
every time!
time!

Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama offers
offers several
several resources
resources to
to help
help provider
provider offices
offices
locate
locate needed
needed information.
information. Resources
Resources include
include our
our web
web site,
site, www.bcbsal.com,
www.bcbsal.com, voice voice
response
response units
units as
as well
well as
as Customer
Customer Service
Service Representatives
Representatives dedicated
dedicated to
to assisting
assisting
providers
providers only.
only.
These
These resources
resources can
can help
help you
you obtain
obtain all
all information
information needed
needed for
for your
your Blue
Blue Cross
Cross and
and
Blue
Blue Shield
Shield of
of Alabama
Alabama patients
patients such
such as
as understanding
understanding benefit
benefit and
and eligibility
eligibility
information,
information, claim
claim rejection
rejection reasons,
reasons, and
and predetermination
predetermination status.
status.

Following
Following is
is information
information that
that you
you need
need when
when contacting
contacting Blue
Blue Cross:
Cross:

Provider
Provider Number
Number
Patient
Patient Contract
Contract Number
Number
Patient
Patient Name
Name
Patient
Patient Date
Date of
of Birth
Birth
At
At the
the end
end of
of this
this course,
course, there
there is
is aa complete
complete list
list of
of telephone
telephone numbers
numbers and
and e-mail
e-mail
addresses
addresses that
that will
will be
be helpful
helpful to
to you.
you.
Voice Response Unit

Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama’s
Alabama’s voice
voice response
response unit
unit (VRU)
(VRU)
can
can be
be reached
reached by
by calling
calling 205
205 988-2213
988-2213 or
or 800
800 648-9807.
648-9807.

Following
Following is
is the
the type
type of
of information
information that
that provider
provider offices
offices can
can receive
receive
by
by calling
calling the
the VRU
VRU 24
24 hours
hours aa day,
day, seven
seven days
days aa week:
week:

Basic
Basic Benefits
Benefits
Claims
Claims Status
Status
Order
Order Remittances
Remittances
Can
Can Be
Be Used
Used if
if Computer
Computer Systems
Systems are
are Down
Down
ProviderAccess is a tool that many
provider offices use to verify their
patients’ eligibility and benefits, file
claims, retrieve audit trails and
remittances, view network fee
schedules and much more.
Claim Re-Filing Report
Re-Filing
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama provides
provides aa Claim
Claim Re-Filing
Re-Filing report
report that
that contains
contains
detailed explanations for claim rejections that are not provided on the remittance.
detailed explanations for claim rejections that are not provided on the remittance.
These
These reports
reports are
are available
available through
through ProviderAccess
ProviderAccess oror mailed
mailed at
at the
the same
same time
time as
as the
the
paper
paper remittance.
remittance.
Claim Re-Filing Report
Re-Filing
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama provides
provides aa Claim
Claim Re-Filing
Re-Filing report
report that
that contains
contains
detailed explanations for claim rejections that are not provided on the remittance.
detailed explanations for claim rejections that are not provided on the remittance.
These
These reports
reports are
are available
available through
through ProviderAccess
ProviderAccess oror mailed
mailed at
at the
the same
same time
time as
as the
the
paper
paper remittance.
remittance.

Here
Here is
is an
an example
example ofof how
how
the
the Claim
Claim Re-Filing
Re-Filing report
report
can
can help
help your
your office:
office:
Claim Re-Filing Report
Re-Filing
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama provides
provides aa Claim
Claim Re-Filing
Re-Filing report
report that
that contains
contains
detailed explanations for claim rejections that are not provided on the remittance.
detailed explanations for claim rejections that are not provided on the remittance.
These
These reports
reports are
are available
available through
through ProviderAccess
ProviderAccess oror mailed
mailed at
at the
the same
same time
time as
as the
the
paper
paper remittance.
remittance.

Here
Here is
is an
an example
example ofof how
how
the
the Claim
Claim Re-Filing
Re-Filing report
report
can
can help
help your
your office:
office:

Notice
Notice Rejection
Rejection Code
Code 16
16 on
on
the
the remittance
remittance example.
example.
Rejection
Rejection reasons
reasons are
are found
found on
on
www.wpc-edi.com/codes/claimadjustment.
www.wpc-edi.com/codes/claimadjustment.
The
The Claim
Claim Re-Filing
Re-Filing report
report provides
provides
the
the detailed
detailed information
information needed
needed toto
successfully
successfully process
process the
the claim.
claim.
System Down Time
If you are unable to access information
electronically, here is how we can help:

For eligibility, call the Voice Response

Unit (VRU) or wait until the system is
back up. If you have an emergency and
the patient is in the office, call Customer
Service and we will provide that
information to you.

For claims, call the VRU or wait until

system is back up.
Computer Problems
If your computer or vendor will be down for a
couple of days, we will provide you needed
information over the telephone for a specified
period of time. Once you have reported your
situation to Customer Service, a Team Leader
will call you.
Provider Network Services
Blue Cross and Blue Shield of Alabama knows
the importance of and values our relationships
with providers participating in our networks.
Provider Network Services Representatives are
dedicated associates that serve as the liaison
between the provider community and Blue Cross
and Blue Shield of Alabama. A Network Services
Representative’s primary responsibilities are to
manage our networks, build relationships,
provide education and assist with problem
identification and resolution.
Provider Network Services
The state is divided into territories and each
territory has a Provider Representative that
travels within that territory. Representatives
visit with individual provider offices and
facilities as well as conduct group meetings.
Durable medical equipment (DME), home
health, hospice and dental have a
Representative specifically assigned to them.

Access the web site shown below to locate your

Provider Representative:

www.bcbsal.com/providers/contacts/NetworkServices.cfm
Provider Network Services
In our corporate office, there are Internal
Representatives that assist the Provider
Representatives by helping to return telephone
calls and research situations identified through a
call or during a visit. The efforts of these team
members allow traveling Representatives to be
in the field more frequently. As mentioned
before, many questions and concerns can be
handled by calling Customer Service. Provider
Network Services gets involved with educational
issues, recurring or more complex questions that
require time and research as well as any
network or contractual issues.
Provider Network Services
Here is a list of Blue Cross and Blue Shield
of Alabama provider networks:
Hospital Occupational Therapist
Physician Durable Medical Equipment
Optometrist Home Health
Chiropractor Hospice
Podiatrist Blue Advantage
Nurse Practitioner Ambulatory Surgery Center
Nurse Midwife
Physical Therapist
Dentist
PPO/HMO

In the healthcare world, you will hear of different

types of insurance coverage. Preferred Provider
Organization (PPO) and Health Maintenance
Organization (HMO) are the most common.
PPO/HMO
Here is a brief explanation of PPOs and HMOs:
PPO/HMO
Here is a brief explanation of PPOs and HMOs:

PPOs agree to pay providers for each covered service that is

provided. This payment method is called Fee for Service. PPOs
usually have a large network of providers for their members to
choose from. Blue Cross and Blue Shield of Alabama is a PPO.
PPO/HMO
Here is a brief explanation of PPOs and HMOs:

PPOs agree to pay providers for each covered service that is

provided. This payment method is called Fee for Service. PPOs
usually have a large network of providers for their members to
choose from. Blue Cross and Blue Shield of Alabama is a PPO.

HMOs pay their providers on a monthly basis. The monthly fee is

based on the number of members participating in this plan. This
payment method is referred to as Fee per Member per Month.
HMOs have a small network of providers.
Participating Providers
What’s a Participating Provider?
Participating Providers:
Are Bound by Agreement
These providers sign a legal agreement with Blue Cross and
Blue Shield of Alabama indicating that they agree to the terms
of the network they are joining. In addition, Blue Cross agrees to
uphold our part of the agreement.
Participating Providers
What’s a Participating Provider?
Participating Providers:
Are Bound by Agreement
Accept a Fee Schedule for Payment
Each provider network has a fee schedule that is used to pay for
covered services. Providers know in advance how much Blue Cross
will pay for each covered service provided.
Participating Providers
What’s a Participating Provider?
Participating Providers:
Are Bound by Agreement
Accept a Fee Schedule for Payment
Hold Members Harmless
In the event a network provider does not follow the terms of an
agreement, the patient (our member) is not responsible for paying
for a service in this situation.
Participating vs.
Non -Participating Providers
Non-Participating
What’s a Participating Provider?
Participating Providers:
Are Bound by Agreement
Accept a Fee Schedule for Payment
Hold Members Harmless

What’s a Non-Participating Provider?

Non-Participating Providers:
Are Not Bound by Agreement
Receive Reduced Reimbursement Based on Member Benefits
Are Not Held Accountable to Hold Harmless Situations
Electronic Data Interchange

Electronic Data Interchange (EDI)

is the computer-to-computer
exchange of information by
electronic means with a minimum
of human intervention.
EDI Services

Blue Cross and Blue Shield of Alabama

strongly encourages providers to take
advantage of Electronic Data Interchange.

EDI Services is a dedicated area that

concentrates on the efficient uses of EDI
for our providers. On the following pages,
we’ll discuss some of the many benefits
of EDI.
How EDI Works for You
With EDI, providers can…
• Access patient eligibility and benefits;
• Submit patient referrals and precertifications;
• File claims electronically, including secondary and corrected claims;
• Receive audit reports on claim submissions;
• Check claim status;
• View fee schedules;
• Receive remittances and payments faster than with paper;
• Access payment history; and
• Much, much more.
How to Get Started with EDI
Following are three ways to connect to
Blue Cross and Blue Shield of Alabama
electronically:

1 Practice Management (PM) Software

2 PCEMC+
3 ProviderAccess
EDI Access
1 A Practice Management
Software System
Your claims may go through
a clearinghouse. Additional
time and charges may occur
in the submission process.

Your claims can come directly

to Blue Cross and Blue Shield
of Alabama from either your
office or the vendor’s site.
EDI Access
2 PCEMC+ Blue Cross
software using a
PC+ Vendor

Your claims can come

directly to Blue Cross
from your office.
EDI Access
3 ProviderAccess
on the Internet
www.bcbsal.com

Your claims go directly

to Blue Cross.
Associated Costs
1 Practice Management (PM) Software
The cost of using a PM software package depends on
your selection and the options or modules you purchase.
Clearinghouses will charge a monthly fee or a per diem.

PCEMC+
2 PCEMC+ software is free of charge.
The PC+ Vendor that you select will charge for
installation and support.

ProviderAccess
3 There is no charge for the use of our Internet
ProviderAccess program.
There will be a charge from your Internet Service
Provider (ISP).
Vendor Functionality Matrix
Blue Cross and Blue Shield of Alabama maintains a
Vendor Functionality Matrix (VFM) for institutional,
professional and dental providers to assist with
selecting a vendor. Each VFM is available on the
Blue Cross web site at the address below:

https://www.bcbsal.org/providers/edi/index.cfm

Only the functions that Blue Cross and Blue Shield

of Alabama validates are represented on the VFM.
Many vendor practice management systems offer
additional features.
EDI Support
When you need help with EDI, contact your
vendor or clearinghouse first.
Call EDI Services at 205 220-6899 for assistance
with the following:

EDI Enrollment
General EDI support
PCEMC+/PC-ACE support
ProviderAccess support
Electronic Funds Transfer
Sign up for Electronic Funds Transfer (EFT)
if your office could benefit from faster claims
payment and patient account reconciliation.

Receive claim payments up to a week earlier

than with paper checks.
Payments will be deposited directly into your
bank account.
Online remittances are available in a printable
format if needed.
Electronic Funds Transfer

All providers are eligible for EFT. However,

National Accounts Service Company (NASCO)
claims are not paid through EFT.
Refunds can be settled through EFT. Once a
refund is requested, the system will wait 75
days before deducting the refund.
The only requirement is that EFT providers
receive online remittances. EFT providers do
not receive paper remittances.
Electronic Funds Transfer
Sign up is easy!

Complete an EFT Authorization Agreement that

is available on Blue Cross and Blue Shield of
Alabama’s web site at the address below:
https://www.bcbsal.org/providers/forms/EFTforBS.pdf

You’ll need to include a voided check or a copy

of a check with your agreement.
Allow four weeks for automatic deposits to
begin. You will continue to receive paper checks
until your automatic deposit begins.
Network Integrity

Mission Statement

To maintain the integrity of our

customer’s healthcare benefits
program as well as our
provider networks.
Network Integrity
Blue Cross and Blue Shield of Alabama’s Network
Integrity department helps to ensure our members,
your patients, receive the best available healthcare.
One roadblock in achieving this goal is the fact that
over $100 million each year is lost to fraud and
abuse. With Americans now spending around $1
trillion on healthcare annually, the demands to
prevent and identify fraud and abuse have never
been more important.
Network Integrity
Healthcare fraud can be defined as knowingly and
willfully committing, or attempting to commit, a
scheme to defraud any healthcare benefit plan or
to obtain by false or fraudulent pretenses,
representations, or promises money or property
owned by any healthcare benefit plan. Here are
some examples of fraud:

• Billing for services not provided.

• Using an incorrect or inappropriate
provider number in order to be paid.
Network Integrity
Abuse may directly or indirectly result in
unnecessary cost, improper payment or payment
for services that fail to meet professionally
recognized standards of care or that are medically
unnecessary. Abuse involves payment for items or
services when there is no legal entitlement to that
payment and the provider has not knowingly
and/or intentionally misrepresented facts to obtain
payment. In many cases, abuse evolves into fraud.
Network Integrity
Following are examples of abuse:

• Using procedure or revenue codes that

describe more extensive services than
those actually performed.

• Billing for services grossly in excess of

those needed by the patient.
How We Achieve Our Mission
Blue Cross and Blue Shield of Alabama monitors
claims and stays in contact with our providers
and members. Following are examples of
incidents or “triggers” that may prompt a
provider review:
• Falling outside peer parameters for specific
procedures and/or diagnoses
• Peer notifications
• Member notifications
• Law enforcement notifications
The Statistics
The National Health Care Anti-Fraud
Association (NHCAA) estimates that of the
1.7 trillion spent annually on the nation’s
health care expenses, 3% is lost to fraud.

3% = $50 billion lost to fraud each year

The Statistics

The Blue Cross and Blue Shield Association

along with the United States Government
Accountability Office estimates for 2003

5% = $85 billion lost to fraud

How to Report Fraud and Abuse

1 800 824-4391

www.bcbsal.com/fraud
Provider Resources
Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama Web
Web Address:
Address: www.bcbsal.com
www.bcbsal.com
Electronic
Electronic Practice
Practice Management
Management (e-PM)
(e-PM) and
and Network
Network Providers:
Providers: 877
877 231-7239
231-7239
Non
Non e-PM
e-PM and
and Non-Network
Non-Network Providers:
Providers: 205
205 988-2213
988-2213 (VRU)
(VRU)
800
800 648-9807
648-9807 (VRU)
(VRU)
205
205 733-7016
733-7016
Primary
Primary Care
Care Network
Network (PCN):
(PCN): 888
888 437-9576
437-9576
BellSouth:
BellSouth: 800
800 252-5238
252-5238
NASCO:
NASCO: 800
800 634-7592
634-7592
Federal
Federal Employee
Employee Program
Program (FEP):
(FEP): 800
800 492-8872
492-8872
General
General Electric
Electric (GE):
(GE): 800
800 655-5392
655-5392
888
888 217-5224
217-5224
EDI
EDI Services
Services (Contact
(Contact Your
Your Vendor
Vendor First):
First): 205
205 220-6899
220-6899
Report
Report Fraud
Fraud and
and Abuse
Abuse (www.bcbsal.com/fraud):
(www.bcbsal.com/fraud): 800
800 824-4391
824-4391

E-mail
E-mail Notification
Notification List:
List: provider_notify@bcbsal.org
provider_notify@bcbsal.org
Glossary of Terms
Abuse
Abuse An An act
act that
that may
may notnot have
have all
all the
the elements
elements ofof fraud,
fraud, but
but that
that takes
takes advantage
advantage of of
aa situation
situation and
and results
results in
in an
an unauthorized
unauthorized benefit.
benefit. The
The person
person more
more than
than likely
likely has
has taken
taken
advantage
advantage of an accepted practice or has found a "loophole" to obtain a benefit for which
of an accepted practice or has found a "loophole" to obtain a benefit for which
they
they are
are not
not entitled.
entitled.

Alternate
Alternate Billing
Billing See
See EMC.
EMC.

Application
Application AA form
form completed
completed by
by aa person
person to
to apply
apply for
for coverage.
coverage.

Assignment
Assignment AA payment
payment method
method under
under medical
medical insurance
insurance in
in which
which payment
payment for
for covered
covered
services
services go
go directly
directly to
to the
the provider.
provider.

Assistant
Assistant Surgeon
Surgeon AA registered
registered medical
medical physician
physician who
who aids
aids aa surgeon
surgeon in
in performing
performing
an operation.
an operation.

Benefits
Benefits Services,
Services, as
as defined
defined in
in the
the insurance
insurance certificate,
certificate, available
available to
to aa member.
member.

Benefit
Benefit Period
Period AA time
time span
span during
during which
which benefits
benefits may
may be
be provided.
provided. While
While the
the benefit
benefit
period is usually a set unit of time, such as a year, benefits may also be tied to a specific
period is usually a set unit of time, such as a year, benefits may also be tied to a specific
illness.
illness. AA benefit
benefit period
period is
is applicable
applicable to
to Blue
Blue Cross
Cross Hospital
Hospital coverage,
coverage, Blue
Blue Shield
Shield
Medical,
Medical, surgical
surgical and
and all
all other
other coverage
coverage not
not aa part
part of
of hospital.
hospital.
Glossary of Terms
Claim
Claim AA request
request for
for payment
payment under
under an
an insurance
insurance contract.
contract.

Coinsurance
Coinsurance AA means
means ofof sharing,
sharing, dividing
dividing or
or splitting
splitting the
the cost
cost of
of services
services between
between the
the
plan
plan and
and the
the subscriber,
subscriber, usually
usually represented
represented inin aa percentage
percentage amount.
amount.

Contract
Contract AA written
written agreement
agreement between
between Blue
Blue Cross
Cross and
and aa subscriber
subscriber for
for specific
specific
coverage.
coverage.

Contract
Contract Maximum
Maximum The
The total
total allowed
allowed to
to be
be paid
paid within
within aa benefit
benefit period
period for
for services
services
rendered
rendered

Contract
Contract Number
Number AA number
number assigned
assigned to
to each
each subscriber
subscriber for
for identification
identification purposes.
purposes.

Conversion
Conversion AA contract
contract offered
offered to
to members
members who
who leave
leave aa group
group and
and change
change to
to aa direct
direct
pay
pay contract.
contract.

Coordination
Coordination of of Benefits
Benefits The
The means
means by
by which
which benefits
benefits paid
paid by
by one
one company
company are
are
reduced
reduced because
because of
of other
other group
group coverage
coverage when
when aa member
member isis covered
covered by
by more
more than
than one
one
contract.
contract.

C
C Plus SM A
PlusSM A contract
contract designed
designed to
to supplement
supplement Medicare
Medicare coverage
coverage
Glossary of Terms
CPT
CPT Physicians’
Physicians’ Current
Current Procedural
Procedural Terminology
Terminology isis aa national
national uniform
uniform numeric
numeric coding
coding
system
system that
that lists
lists descriptive
descriptive terms
terms and
and identifying
identifying codes
codes for
for reporting
reporting medical
medical services
services
and
and procedures
procedures performed
performed by by physicians
physicians to
to assure
assure consistency
consistency in in coding
coding claims.
claims.

Coverage
Coverage The
The extent
extent of
of benefits
benefits provided
provided by
by aa subscriber’s
subscriber’s contract.
contract.

Customary
Customary Charge
Charge The The Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama’s
Alabama’s customary
customary charge
charge isis
the
the 90th
90th percentile
percentile of
of the
the range
range of
of usual
usual charges
charges for
for the
the same
same oror aa similar
similar service
service billed
billed
by
by most
most physicians
physicians with
with similar
similar training
training and
and experience
experience within
within the
the same
same geographic
geographic area.
area.

Deductible
Deductible The
The amount
amount to
to be
be paid
paid by
by the
the subscriber
subscriber first
first for
for aa hospital
hospital admission
admission or
or
Major
Major Medical
Medical claim
claim during
during the
the calendar
calendar year
year before
before aa contract
contract will
will make
make benefit
benefit
payments.
payments.

Dependent
Dependent AA member
member covered
covered under
under aa subscriber's
subscriber's family
family contract
contract such
such as
as aa spouse
spouse or
or
aa child. Direct Pay Contract The premium is paid directly from the subscriber to Blue
child. Direct Pay Contract The premium is paid directly from the subscriber to Blue
Cross.
Cross.

DRG
DRG Diagnosis
Diagnosis related
related groups
groups (DRGs)
(DRGs) are
are aa system
system for
for payment
payment toto hospitals
hospitals for
for
inpatient
inpatient services
services under
under Medicare
Medicare Part
Part AA and
and are
are based
based onon prospectively
prospectively set
set rates.
rates.
Medicare
Medicare payment is made at a predetermined, specific rate for each hospital discharge.
payment is made at a predetermined, specific rate for each hospital discharge.
All discharges are classified according to a list of DRGs.
All discharges are classified according to a list of DRGs.
Glossary of Terms
EDI
EDI Electronic
Electronic Data
Data Interchange
Interchange (EDI)
(EDI) refers
refers to
to the
the use
use of
of electronic
electronic transactions
transactions for
for
exchange
exchange patient
patient and
and claim
claim information
information between
between Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama
and
and our
our affiliated
affiliated providers.
providers. TheThe electronic
electronic information
information network
network of of Blue
Blue Cross,
Cross, known
known asas
e-Practice
e-Practice Management
Management (e-PM),
(e-PM), offers
offers electronic
electronic connections
connections for
for EDI
EDI transactions
transactions
through
through various Practice Management software systems, the PCEMC+ software,
various Practice Management software systems, the PCEMC+ software, and
and our
our
online web site applications.
online web site applications.

Effective
Effective Date
Date The
The date
date coverage
coverage begins.
begins.

EMC
EMC Electronic
Electronic Media
Media Claims
Claims (EMC)
(EMC) refers
refers to
to the
the electronic
electronic transmission
transmission of
of medical
medical
claims.
claims.

e-PM
e-PM e-Practice
e-Practice Management
Management (e-PM)
(e-PM) is
is the
the electronic
electronic information
information network
network ofof Blue
Blue Cross
Cross
offering
offering electronic
electronic connections
connections for
for EDI
EDI transactions
transactions through
through various
various Practice
Practice Management
Management
software
software systems,
systems, the
the PCEMC+
PCEMC+ software,
software, and
and our
our online
online web
web site
site applications.
applications.

Endorsement
Endorsement AA provision
provision added
added to
to aa subscriber's
subscriber's contract
contract that
that changes
changes the
the scope
scope of
of its
its
coverage
coverage

Exclusions
Exclusions Specified
Specified conditions
conditions for
for which
which aa subscriber's
subscriber's contract
contract will
will not
not provide
provide
benefits
benefits
Glossary of Terms
Explanation
Explanation of of Benefits
Benefits AA computer-written
computer-written statement
statement sent
sent to
to aa subscriber
subscriber or
or
provider
provider that
that explains
explains action
action taken
taken on
on each
each claim.
claim.

FEP
FEP Federal
Federal Employee
Employee Program
Program (FEP)
(FEP) is
is aa group
group health
health care
care program
program designed
designed for
for
federal employees and their dependents.
federal employees and their dependents.

Filing
Filing Limitation
Limitation AA timely
timely filing
filing provision
provision that
that requires
requires that
that claims
claims must
must be
be received
received for
for
payment
payment for
for services
services that
that were
were rendered
rendered or
or expenses
expenses incurred
incurred within
within aa certain
certain timeframe
timeframe
from
from the
the date
date of
of service.
service.

Fraud
Fraud TheThe intentional
intentional deception,
deception, concealment,
concealment, or or misrepresentation
misrepresentation that
that an
an individual
individual
or
or entity
entity makes,
makes, knowing
knowing that
that the
the misrepresentation
misrepresentation could
could bring
bring some
some benefit
benefit to
to them
them or
or
another
another party
party that
that they
they are
are not
not legally
legally entitled
entitled to
to receive.
receive.

Group
Group AA business
business or
or organization
organization that
that has
has aa contract
contract with
with Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of
Alabama to provide a benefits plan for its employees or members.
Alabama to provide a benefits plan for its employees or members.

Group
Group Number
Number AA common
common identification
identification number
number assigned
assigned to
to all
all covered
covered individuals
individuals in
in
aa group.
group.

HCFA
HCFA Health
Health Care
Care Financing
Financing Administration
Administration –– this
this is
is the
the previous
previous name
name of
of the
the entity
entity that
that
is now known as the Centers for Medicare and Medicaid Services
is now known as the Centers for Medicare and Medicaid Services (CMS).(CMS).
Glossary of Terms
HCPCS
HCPCS HCFA HCFA Common
Common Procedure
Procedure Coding
Coding System
System (HCPCS)
(HCPCS) isis aa structured
structured coding
coding system
system
that
that includes
includes American
American Medical
Medical Association
Association (AMA)
(AMA) CPT
CPT codes
codes supplemented
supplemented by by nationally
nationally
HCFA-assigned
HCFA-assigned andand local
local carrier
carrier assigned
assigned codes.
codes. Unlike
Unlike CPT,
CPT, the
the HCPCS
HCPCS codes
codes and
and
modifiers
modifiers may
may contain
contain alphabetic
alphabetic characters.
characters.

HIPAA
HIPAA Health
Health Insurance
Insurance Portability
Portability and
and Accountability
Accountability Act
Act (HIPAA)
(HIPAA) ofof 1996
1996 -- Under
Under the
the
Administrative
Administrative Simplification
Simplification provisions
provisions (Title
(Title II)
II) of
of HIPAA,
HIPAA, the
the Department
Department of of Health
Health and
and
Human
Human Services
Services has
has established
established national
national standards
standards forfor electronic
electronic health
health care
care transactions
transactions
and
and national
national identifiers
identifiers for
for providers,
providers, health
health plans
plans and
and employers.
employers. It
It also
also addresses
addresses the
the
security
security and
and privacy
privacy of
of electronic
electronic health
health information.
information.

HMO
HMO AA Health
Health Maintenance
Maintenance Organization
Organization (HMO)
(HMO) isis aa health
health care
care system
system thatthat assumes
assumes or
or
shares
shares both
both the
the financial
financial risks
risks and
and the
the delivery
delivery risks
risks associated
associated with
with providing
providing
comprehensive
comprehensive medical
medical services
services to
to aa voluntarily
voluntarily enrolled
enrolled population
population in
in aa particular
particular
geographic
geographic area,
area, usually
usually in
in return
return for
for aa fixed,
fixed, prepaid
prepaid fee.
fee.

Home
Home Plan Plan The
The Blue
Blue Cross
Cross Plan
Plan providers
providers oror subscribers
subscribers send
send claims
claims to
to when
when the
the
subscriber
subscriber receives
receives medical
medical care
care in
in aa different
different Plan’s
Plan’s geographic
geographic area.
area. AA group’s
group’s Home
Home
Plan
Plan is
is the
the Plan
Plan that
that has
has control
control of
of the
the group.
group.

Host
Host Plan
Plan The
The Blue
Blue Cross
Cross Plan
Plan associated
associated with
with the
the provider
provider that
that furnishes
furnishes services
services to
to aa
subscriber
subscriber from
from aa different
different Plan.
Plan. It
It is
is aa Plan
Plan that
that helps
helps the
the Home
Home Plan
Plan service
service the
the group.
group.
Glossary of Terms
ICD-9-CM
ICD-9-CM The The International
International Classification
Classification ofof Diseases-9th
Diseases-9th Revision-Clinical
Revision-Clinical Modification
Modification
is
is aa coding
coding system
system that
that is
is used
used to
to identify
identify aa patient's
patient's diagnosis
diagnosis or
or nature
nature of
of illness
illness or
or
injury.
injury. The
The codes
codes contain
contain upup to
to five
five digits.
digits. Codes
Codes beginning
beginning with
with EE or
or M
M should
should notnot be
be
used
used filing
filing claims.
claims.

Identification
Identification Card
Card Card
Card issued
issued to
to each
each subscriber
subscriber giving
giving his/her
his/her name,
name, coverage,
coverage,
effective
effective date
date of
of current
current coverage,
coverage, and
and waiting
waiting period
period information.
information.

Indemnity
Indemnity AA fixed
fixed dollar
dollar payment
payment for
for aa specified
specified health
health care
care service.
service.

Julian
Julian Date
Date AA number
number that
that represents
represents the
the day
day of
of the
the year,
year, for
for example:
example: January
January 11 ==
001
001 December
December 31
31 =
= 365.
365. This
This number
number is
is used
used on
on claims
claims to
to show
show the
the date
date of
of receipt,
receipt,
for
for example:
example: Blue
Blue Cross
Cross physician
physician claim
claim 555-0096865
555-0096865 represents
represents January
January 9.
9.

Medicare
Medicare Advantage
Advantage The
The name
name for
for Medicare
Medicare +
+ Choice
Choice plans.
plans. If
If you
you have
have one
one of
of these
these
plans, you don’t need a Medigap policy. The Medicare Advantage plan that Blue
plans, you don’t need a Medigap policy. The Medicare Advantage plan that Blue CrossCross
offers
offers is
is called
called BlueAdvantage.
BlueAdvantage.

Major
Major Medical
Medical Coverage
Coverage for
for physician
physician services
services and
and other
other covered
covered medical
medical expenses.
expenses.
At
At Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama,
Alabama, the
the term
term refers
refers to
to coverage
coverage to
to supplement
supplement
Blue
Blue Cross (hospital) or Blue Shield (physician) benefits. Examples of services typically
Cross (hospital) or Blue Shield (physician) benefits. Examples of services typically
covered under Major Medical include prescription drugs, Durable Medical Equipment
covered under Major Medical include prescription drugs, Durable Medical Equipment
(DME),
(DME), ambulance
ambulance service,
service, and
and mental
mental and
and nervous
nervous services.
services.
Glossary of Terms
Maximum
Maximum Allowance
Allowance The
The maximum
maximum dollar
dollar amount
amount that
that aa health
health plan
plan will
will pay
pay toward
toward
the
the cost
cost of
of aa service.
service.

Medical
Medical Emergency
Emergency AA sudden
sudden and
and unexpected
unexpected illness
illness which
which is
is severe
severe enough
enough to
to
require immediate medical care.
require immediate medical care.

Member
Member An
An individual
individual (employee
(employee or
or dependent)
dependent) covered
covered under
under aa contract.
contract.

Non-Assignment
Non-Assignment When When aa physician
physician chooses
chooses not
not to
to accept
accept payments
payments directly
directly from
from the
the
carrier
carrier (Blue
(Blue Cross).
Cross). Participating
Participating providers
providers must
must accept
accept assignment.
assignment.

Non-covered
Non-covered charges
charges Charges
Charges for
for items
items not
not covered
covered under
under aa health
health insurance
insurance
contract.
contract.

Non-Participating
Non-Participating AA provider
provider that
that does
does not
not have
have aa signed
signed contract
contract with
with Blue
Blue Cross
Cross
agreeing
agreeing to the conditions of one or more of our participating networks, or when aa
to the conditions of one or more of our participating networks, or when
network
network isis not
not available
available for
for that
that specialty.
specialty. Also
Also referred
referred to
to as
as Non-PAR
Non-PAR providers.
providers. Non-
Non-
PAR
PAR providers
providers may
may oror may
may not
not choose
choose assignment
assignment whenwhen submitting
submitting aa claim
claim and
and may
may
collect
collect their
their charges
charges from
from the
the subscriber
subscriber since
since the
the subscriber
subscriber isis ultimately
ultimately responsible
responsible for
for
payment.
payment.

NPI
NPI The
The national
national provider
provider number
number (NPI)
(NPI) is
is aa national
national provider
provider identifier
identifier required
required per
per
HIPAA
HIPAA legislation.
legislation.
Glossary of Terms
Participating
Participating AA provider
provider that
that participates
participates in in one
one of
of the
the many
many networks
networks Blue
Blue Cross
Cross
offers
offers (PMD,
(PMD, Radiology,
Radiology, Physical
Physical Therapy,
Therapy, Primary
Primary Care,
Care, etc.)
etc.) The
The participating
participating provider
provider
signs
signs aa contract
contract to
to accept
accept assignment
assignment forfor all
all services
services provided
provided toto our
our subscribers
subscribers and
and
also
also agrees
agrees to
to accept
accept the
the fee
fee schedule
schedule amount
amount as as payment
payment in in full
full for
for the
the covered
covered
services. Also referred to as PAR providers.
services. Also referred to as PAR providers.

Payer
Payer An
An entity
entity that
that reimburses
reimburses health
health care
care claims
claims such
such as
as Blue
Blue Cross
Cross and
and Medicare.
Medicare.

Payment
Payment The
The amount
amount paid
paid to
to the
the provider
provider for
for services
services rendered.
rendered.

PCEMC+
PCEMC+ Personal
Personal Computer
Computer Electronic
Electronic Media
Media Claims
Claims Plus
Plus (PCEMC+)
(PCEMC+) is is aa Windows-
Windows-
based
based application
application developed
developed by
by Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama.
Alabama. TheThe PCEMC+
PCEMC+
software
software offers
offers aa provider
provider the
the capability
capability to
to enter
enter and
and transmit
transmit inin an
an electronic
electronic file
file to
to Blue
Blue
Cross.
Cross. It
It also
also offers
offers electronic
electronic access
access to
to patient
patient account
account and
and claim/payment
claim/payment information.
information.

Per
Per Diem
Diem Usually
Usually refers
refers to
to hospital
hospital reimbursements
reimbursements that
that are
are paid
paid according
according to
to aa daily
daily
rate.
rate.

Plan
Plan Blue
Blue Cross
Cross and
and Blue
Blue Shield
Shield of
of Alabama
Alabama or
or the
the benefits
benefits offered
offered under
under aa health
health
benefits
benefits contract.
contract.

Plan
Plan Code
Code First
First three
three digits
digits of
of the
the eight-digit
eight-digit provider
provider number
number
Glossary of Terms
PPO
PPO AA Preferred
Preferred Provider
Provider Organization
Organization (PPO)
(PPO) is
is aa system
system ofof health
health care
care organized
organized by by an
an
insurance
insurance company
company forfor groups.
groups. Physicians,
Physicians, health
health care
care providers
providers ofof all
all types
types including
including
hospitals
hospitals and
and clinics
clinics sign
sign contracts
contracts with
with the
the PPO
PPO system
system toto provide
provide care
care toto its
its insured
insured
people.
people. These
These medical
medical providers
providers accept
accept the
the PPO’s
PPO’s fee
fee schedule
schedule and
and guidelines
guidelines for for its
its
managed medical care.
managed medical care.

Preadmission
Preadmission Certification
Certification AA program
program designed
designed to
to assure
assure members
members in in advance
advance that
that aa
hospital
hospital inpatient
inpatient admission
admission is
is medically
medically necessary.
necessary. Also
Also called
called aa percert.
percert.

Pre-Existing
Pre-Existing Condition
Condition AA condition
condition that
that existed/exists
existed/exists prior
prior to
to the
the effective
effective date
date of
of
the contract.
the contract.

Primary
Primary Care
Care Network
Network AA network
network of
of physicians
physicians who
who participate
participate in
in Blue
Blue Cross
Cross and
and Blue
Blue
Shield
Shield of
of Alabama’s
Alabama’s point
point of
of service
service product.
product.

Provider
Provider AnAn institution,
institution, individual,
individual, or
or organization/business
organization/business that
that provides
provides health
health care
care
services and/or supplies.
services and/or supplies.

Provider
Provider Number
Number The The identifying
identifying number
number assigned
assigned to
to aa physician
physician by
by aa payer
payer for
for filing
filing
claims.
claims. Also
Also referred
referred to
to as
as aa legacy
legacy number.
number.

Riders
Riders Coverage
Coverage purchased
purchased by
by aa group
group to
to provide
provide additional
additional benefits.
benefits.
Glossary of Terms
Secondary
Secondary Carrier
Carrier The
The contract
contract which
which pays
pays the
the balance
balance (or
(or up
up to
to contract
contract limits)
limits) when
when
aa member
member has
has two
two contracts
contracts and
and primary
primary benefits
benefits are
are provided
provided by
by the
the other
other contract.
contract.

Subscriber
Subscriber The
The person
person to
to whom
whom aa contract
contract is
is issued
issued

Total
Total Charge
Charge The
The total
total charge
charge submitted
submitted by
by the
the provider
provider

UCR
UCR TheThe usual,
usual, customary,
customary, and and reasonable
reasonable (UCR)
(UCR) fee
fee is
is the
the amount
amount ofof aa physician’s
physician’s
charge
charge that
that Blue
Blue Shield
Shield will
will recognize
recognize for
for payment
payment for
for his/her
his/her medically
medically necessary
necessary
services
services covered
covered by
by aa subscriber’s
subscriber’s contract.
contract.

VRU
VRU AA voice
voice response
response unit
unit is
is an
an automated
automated response
response telephone
telephone line
line used
used to
to request
request
information.
information.

Waiting
Waiting Periods
Periods TheThe time
time aa person
person must
must wait
wait after
after the
the effective
effective date
date of
of the
the contract
contract
before benefits for pre-existing conditions are available.
before benefits for pre-existing conditions are available.

Waivers
Waivers No
No waiting
waiting periods
periods for
for preexisting
preexisting conditions
conditions are
are set
set on
on aa contract.
contract.
Thank you for taking Blue Cross 101!
We
We hope
hope this
this information
information proves
proves helpful
helpful to
to you.
you. Please
Please submit
submit ideas
ideas for
for
improvements
improvements oror additional
additional courses
courses to
to provider_notify@bcbsal.org.
provider_notify@bcbsal.org.

An Independent Licensee of the Blue Cross and Blue Shield Association.