Loading presentation...

Present Remotely

Send the link below via email or IM


Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.


Copy of Copy of Common Types of Commercial Insurance

No description

Monica Garcia

on 14 August 2015

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Copy of Copy of Common Types of Commercial Insurance

Health Insurance Plans
design by Dóri Sirály for Prezi

What is it?
Insurance plan that allows members to direct their own health care and generally visit any doctor or hospital
Do not use a network of providers like a PPO or HMO
Some indemnity plans require the member to pay the provider for services out of pocket and submit a claim for reimbursement
Bottom Line:
Members have flexibility to see providers without any restrictions

Common Types of Publicly Funded Insurance
Government-sponsored health-care plans are insurance plans that are sponsored by either the state or the federal government
State Medicaid systems
Tricare, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Indian Health Services (IHS)

What is it?

An insurance plan that provides healthcare services through a network of providers
Better access to preventative care
Members are not able to see providers out of the network without prior authorization from the insurance company
Bottom Line:

A restrictive plan, but provides lower premiums

Common Types of Commercial Insurance
PPO Health Insurance Plans
Indemnity Health Insurance Plans
Self-funded Insurance Plans
HMO Health Insurance Plans
HSA-Qualified Health Insurance Plans
Point of Service Insurance Plans
Health Insurance Exchange

What is it?
An insurance plan that provides members with more coverage if they choose to see providers approved by or affiliated with the plan
Members are able to see other providers as well but with a higher out of pocket expense
Bottom Line:
Members have the flexibility to see providers in or out of network

What is it?

A high deductible insurance plan that provides a bank account used for contributions to pay for qualified medical expenses
A bank card is issued to the member

Bottom Line:

Provides flexibility to use physicians in or out of network and has lower premiums due to the member’s greater share in health costs

What is it?
Employer sets aside funds to pay anticipated health insurance claims for their employees
Employers using this option may elect to have a third party administrator to process all claims and paperwork

Bottom Line:

Benefit design (coverage benefits) is infinitely flexible and can be tailored to suit the employer’s budget and workforce

What is it?

A type of managed care plan that is a hybrid of HMO and PPO plans
Similar to an HMO, participants designate an in-network physician to be their primary care provider
Similar to a PPO, patients may go outside of the provider network for health care services

Bottom Line:

Combined advantages of HMO’s and PPO’s

What is it?
Medicare is a government (social security) health insurance plan for people who are:
65 or older
Under 65 with certain disabilities
Have end-stage renal disease

Medicare Insurance Part A and B

What is it?

Independent insurance companies manage the processing of claims on Medicare's behalf

Benefits / Coverage:

Available to anyone over the age of 65 currently covered by Medicare Parts A and B
An additional premium payment is required in addition to the premium paid for Part B

Medical Necessity Advanced Beneficiary Notice (ABN)

What is an ABN?
An Advanced Beneficiary Notice (ABN), also
known as a 'waiver of liability'
Validation of charge codes and diagnosis codes for procedures, Radiology services, lab services
Provider determines need for an ABN validation
Provider provides the charge code(s) and diagnosis code(s) to the LPN/MA
LPN/MA enters the provided codes into Flowcast for validation
The codes are bounced up against Medicare Guidelines
If the codes return with a 'Not Covered' status, the 'Waiver of Liability' is printed
The provider presents the waiver to the patient with options
Option 1:
Procedure is done, Medicare is billed, and the patient accepts financial responsibility for the remaining balance
Option 2:
Procedure is done and the patient chooses to pay in full at time of services without claim submission to Medicare
Option 3:
Procedure is not done and alternative options are provided to the patient

What is it?

Medicaid is a partnership between each state and the federal government to provide low cost or no cost medical care to those who need it most
Low income
Needy families with dependent children

What is it?
Centennial Care is the new name of New Mexico’s Medicaid program
Its design creates a single, comprehensive delivery system through four managed care plans
Allows for greater administrative simplicity
Emphasizes care coordination so that recipients will receive the right care, in the right place, at the right time, leading to better health outcomes

Resource: NMHSD PRESS RELEASE 2013 - Human Services Department Announces Select of Centennial Care Managed Care Organizations

What is it?

A Military Health System
Combines health care resources at military hospitals and clinics or direct care with networks of civilian health care professionals and hospitals
The Tricare health program is organized into four geographic health service regions
New Mexico is included in the West Region

Preferred Provider Organization
Health Maintenance Organization (HMO) Health Insurance
Indemnity Plans
HSA-Qualified Health Insurance
Health Savings Account
Self Funded Health Insurance
Point of Service Insurance
Medicare Advantage
Insurance (Part C)
Medicare Benefits Coverage
Medicaid Insurance
Tricare / Champus Insurance
Eligibility guidelines are set on a federal level and are the same nationwide

Health Insurance Exchange
What is it?
Healthcare reform
Commercial plans
Purchased by individuals and small business owners
Plan criteria varies based on the insurance company providing the coverage
ABQ Health Partners Contracted Health Insurance Exchange plans
Blue Advantage HMO
Blue Community HMO
Molina Gold Plan
Molina Silver Plan
Molina Bronze Plan
New Mexico Health Connections

What is Health Insurance?

A way to pay for healthcare
Protection from paying the full cost of medical services when injured or sick
Health insurer agrees to paying a portion of the covered medical costs
Payments made by the insurance company are typically based on amounts negotiated with providers/hospitals
Provided by employers, the Government, or are purchased individually
Member selects the plan of choice
The member agrees to pay a certain rate or premium each month
Contracts Between
Health Plans and Provider Practices
Contract negotiations take place between the insurance companies and the provider practice
Generally speaking, information contained in the contract can be grouped into 5 broad categories

Language distinctions provide the framework for the relationship between the provider and the health plan
Does the term “clean claim” mean the same to the health plan as it does to the provider practice
The provider practice definition of a clean claim may be to focus on submission of a standardized claim form with all fields completed and all information required for the processing of the claim
The health plans definition of the clean claim may be all of the above to include the utilization of appropriate health plan coding standards
The misinterpretation of the term “clean claim” may result in increased claim denials or delayed payments

Health Plans Obligations
Responsibilities of the health plan or its affiliated payers to the provider practice
Does the health plan offer electronic business solutions that can reduce the practice expenses and increase workflow efficiencies?
If the health plan requires authorizations, does it offer electronic authorization capabilities?

Provider Practice Obligations
Responsibilities of the provider practice
to the health plan
Are the timely filing requirements reasonable for the practice?
How much time does the provider practice have to submit clean claims to the health plan for payment?

Terms and Termination
Duration of the contract
How long will the contract be valid between the health plan and the provider practice?
What are the terms for the termination of the contract?

General Provisions
Provides the location for the health plan attorneys to address any miscellaneous legal issues
Is the provider practice afforded the same legal rights and protection as the health plan?

ABQ Health Partners Credentialing and Contracting services are managed by

Andy Baatz Executive Director Contracting
Summer Bloise Credentialing Manager

Glossary of Terms
A specified fee paid by the patient to see a provider, for other services, or to fill prescriptions
A specified percentage, that a patient must pay towards medical expenses after the insurance company pays for their agreed upon portion (e.g: For a $100 medical claim, if the member has insurance with 80/20 coverage, the insurance company would pay $80 and the member would pay the remaining $20)
A specified amount, usually on an annual basis that a patient must pay towards medical expenses before the insurance company begins paying. Generally, the higher the deductible amount, the lower the premium
ABN Process Overview
* To learn more, enroll into the Flowcast ABN course
Tricare Prime
Eligible beneficiaries are active duty service members and their families
Retired service members and their families
Non-activated National Guard/Reserve members and their families who qualify for care under the Transitional Assitance Management Program
Retired National Guard/Reserve members and their families
Age 60 and receiving retired pay
Medal of Honor recipients and their families
Qualified former spouses
ABQ Health Partners will submit claims for this plan
Tricare Standard and Extra
A fee for service plan
Available to all beneficiaries except active duty service members to include activated National Guard/Reserve members
Standard option
Non-network providers
Patient pays higher cost shares
ABQ Health Partners does not file claims for this plan
The patient must pay out of pocket at time of services and submits his/her own claims
Extra option
Network Providers (ABQ Health Partners providers are
network providers)
Patient pays lower cost shares
Claims are submitted by the providers on behalf of the patient
Tricare for Life
Secondary coverage to Medicare for all Tricare beneficiaries who have both Medicare Parts A and B
Services covered by both Medicare and Tricare
Medicare pays first and Tricare for Life pays the remaining co-insurance for Tricare covered services
Services covered by Tricare but not by Medicare
Tricare for Life pays first Medicare pays nothing
The patient is responsible to pay the Tricare fiscal year deductible and cost shares
Services covered by Medicare but not by Tricare
Medicare pays first and Tricare for Life pays nothing
The patient must pay the Medicare deductible and co-insurance
Services not covered by Medicare or Tricare
Medicare and Tricare pay nothing
The patient is responsible to pay the entire bill
Resource http://www.tricare.mil
Resource http://www.tricare.mil
Resource http://www.tricare.mil
Fee For Service
Payment model in which providers are paid for each service rendered to a patient
Patient is seen by a provider
The provider enters charges into the Electronic Health Record
The charges interface to Flowcast for claims submission be it hard copy or electronically
The insurance company reviews the claim and determines if payment is warranted or if additional information or corrections are needed to substantiate payment
If the insurance company feels that payment is warranted, a check is issued to ABQ Health Partners
If the insurance company feels that additional information or corrections are necessary, the claim is denied and returned to ABQ Health Partners
This process is ongoing for each and every visit separately
Managed Care
Also Known As
Total Patient Care or Capitated
Payment model in which fixed payments are paid to the provider practice for enrolled members
Regardless of the number of visits or required treatments, the cost is extracted from the fixed payment
The claim does not need to be submitted to the insurance company to review for payment because the payment has already been provided
Claims are still submitted to the insurance company to keep them apprised of the services the patient is recieving
There are guidelines that must be followed to ensure that the patients recieve care at the right time, in the appropriate setting
ABQ Health Partners Care Management team facilitates this process
What does Medicare Part A cover?

Inpatient care in hospitals
Skilled nursing facilities
Home health care

What does Medicare Part B cover?
Doctor and other health care providers' services
Outpatient care
Durable medical equipment
Home health care
Some preventive services

Non-Covered Services:
If certain services are required that Medicare doesn't cover, the patient will pay out of pocket unless they have alternate insurance that covers the charges. Examples: Long term care, hearing aids, dentures

The four managed care plans are:
Centennial Blue Cross Blue Shield New Mexico
Centennial United Healthcare Community Plan
Centennial Molina Healthcare of New Mexico, Inc.
Centennial Presbyterian Health Plan, Inc.

Coordination of Benefits
What is it?
The process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance company
Primary Coverage
If a person is covered under more than one health insurance plan, primary coverage is the coverage provided by the health insurance plan that pays on claims first
Secondary Coverage
The health insurance plan that provides payment on claims after the primary insurance plan has paid
Tertiary Coverage
The health insurance plan that provides payment on claims after the primary and secondary insurance plans have paid
*Reference the 'Glossary of Terms' for addtional terms and their descriptions
ABQ Health Partners Contracted Payer List
For a full list of ABQ Health Partners contracted payors
Access the ABQ Health Partners intranet homepage
Select 'Revenue Operations'
Select the '2014 Contracted Payer List'
Blue Cross Blue Shield Commercial Plans
All Blue Cross Blue Shield commercial plan claims are billed through the local BC/BS of New Mexico branch
BC/BS of NM will process claims accordingly to the applicable out of state branches
Blue Cross Blue Shield Medicare Advantage
New Mexico

Members may or may not be capitated
Capitated members are assigned to an ABQ Health Partners provider
Non capitated members are
assigned to an ABQ Health Partners provider
Presbyterian City of Albuquerque
The City of Albuquerque employer group is contracted with ABQ Health Partners
The employer group consists of many different entities
Bernalillo County
City of Belen
Middle Rio Grande Conservancy District
Sandoval County
Southern Sandoval County Arroyo Flood Control
Town of Bernalillo
Town of Cochiti Lake
Town of Edgewood
Town of Mountainair
Village of Bosque Farms
Village of Corrales
Village of Cuba
Village of Los Ranchos
Village of Tijeras
Village of San Ysidro
Presbyterian Retirees
ABQ Health Partners can submit claims for Presbyterian retirees if they have out of network benefits
If the retiree does not have out of network benefits and Presbyterian will not provide an authorization, the patient is 'self pay'
They are not eligible for the 25% discount
Presbyterian Centennial
A Presbyterian issued authorization is required in order for ABQ Health Partners to be able to submit claims
Molina Healthcare
New Mexico Health Insurance Exchange
ABQ Health Partners contracted plans
Molina Gold Plan
Molina Silver Plan
Molina Bronze Plan
Molina Centennial
Group assignment must be with ABQ Health Partners
If the group assignment is with UNMH providers and facilities, the patient must seek care at UNMH or First Choice
The patient is welcome to contact Molina Healthcare to have the group assignment changed to ABQ Health Partners if they so choose
UNM Medical Plan
Also Known As Lobocare
Plan is provided by the University of New Mexico for its employees and dependents
There are 2 options provided to members outside of the UNMH provider network and facilities
Lovelace UNM Medical Plan
Presbyterian UNM Medical Plan
Lovelace UNM Medical Plan members can seek treatment at either UNMH or ABQ Health Partners
Presbyterian UNM Medical Plan members can seek treatment at either UNMH or Presbyterian
Presbyterian UNM Medical Plan members with out of network benefits can also seek treatment at ABQ Health Partners
The out of pocket expense will be higher then if seen in-network
*To learn more, enroll into the 'Claim and Statement Basics session
Blue Cross Blue Shield Medicare Advantage
Members are
Blue Cross Blue Shield Medicare Advantage
Out of State

Members are
Clean Claim Defined
A clean claim has no defect, impropriety or special circumstance

Unclean Claim Defined
A defect or impropriety shall include lack of required documentation or circumstance requiring special treatment that delay’s timely payment
What does that mean?
This means a claim can be processed without requiring additional information from the provider of service

An unclean claim is a claim that has to be returned to the provider for additional information

What can we do?
Verify the patient’s insurance each time we have patient contact
When calling / checking for eligibility verify at the same time if an authorization or referral is required for the service
Leave a note in General Comments with referral/prior authorization details


Prior Authorization


Is a requirement from the health plan for approval of specific procedures, such as surgical procedures, DME (Durable Medical Equipment), inpatient stays, radiology services (CT scans, MRI’s, etc.)

Why are they needed?
The reason insurers require pre-approvals is so they can confirm medical necessity – treatment prescribed by the doctor is appropriate for the patient’s condition.
By confirming medical necessity the insurer also helps to control health care cost by reducing duplication, waste, and unnecessary treatment

What can we do?
When calling / checking for eligibility verify at the same time if an authorization or referral is required for the service

Leave a note in General Comments with referral/prior authorization details

Ensure the authorization is linked to the scheduled appointment at the time of scheduling

What happens if we don't get them?
Without this prior approval, the health plan may not provide coverage, or pay for the procedures

What is Timely Filing?
Time frame set by each individual insurance company that requires providers to submit claims within said period of time for payment of services

What does that mean?
If ABC insurance company's timely filing guideline is 90 days, then ABQ Health Partners must submit claims within that period of time in order for the insurance company to pay us for services rendered to the patient
What happens if you don't send claims out within the timely filing limit?
They get denied
What can you do?
…If the patients insurance information is verified and all current information is uploaded and accurate, we can be comfortable knowing that we are sending clean claims out the door and reimbursement isn’t too far behind
Indian Health Services
What is it?
Indian Health Services (IHS) is the health care system for federally recognized American Indian and Alaska Natives in the United States
IHS is not a health insurance provider and will only provide healthcare to eligible American Indians and Alaska Natives at federal hospitals and clinics
IHS is not an entitlement program, such as Medicare or Medicaid
IHS is not an insurance program
IHS is not an established benefits package

Bottom Line

Contract Health Services (CHS) are services that IHS is unable to provide in its own
facilities. CHS are provided by non-IHS health care providers and facilities. CHS payments are authorized based on clearly defined guidelines and are subject to availability of funds


What does that mean?
Full transcript