BLUE CARD/ SF/RF/DF

All Blue Cross Blue Shield (BCBS) plans participate in the

BlueCard program.

• True

• False

ITS is a system for the Blue plans to manually send

claims to each other for local pricing advantages.

• True

• False

Par Plan/ Host Plan establishes and maintains the provider networks.

• True

• False

The Home Plan is not responsible for issuing ID cards or member EOB's.

• True

• False

The BCBSA is responsible for

• issuing ID cards

• training providers

• policies and provisions

• EOB

A Submission Format is

• used by the Home Plan to communicate adjudicated claim data to the Host Plan

• responsible for determining benefits

• used to determine eligibility and

  coverage

• used by the Host Plan to submit claim information to the Home Plan

Reconciliation Format (RF)

• calculates member

  (subscriber) and Plan

  liabilities

• is used by the HOST Plan to request reimbursement from the

  Home Plan

• Pays the provider for

  services rendered

CFA

• Provides daily funds transfer and reporting for

  out-of-area and national account claims

• Processes capitated billing (Per Member Per Month)

  for managed care accounts

• Neither A or B

• Both A and B

Par/Host Plan is responsible for:

• bundling/unbundling practices

• all claims coding (e.g. procedure codes, revenue codes, diagnosis codes, etc.).

• A but not B

• Neither A nor B

• Both A and B

Provider submits the claim to the

host plan

• True

• False