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Glossary

  1. #

    24-hour coverage
    A plan under which an employer's group health plan, disability plan, and workers' compensation program are merged, integrated or coordinated (depending on state regulations) into a single health benefit plan that covers employees 24 hours a day.
    24-hour managed care
    The application of managed care principles to 24-hour coverage.
  2. A

    accreditation
    An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
    ACD
    See automatic call distributor.
    ACF
    See ambulatory care facility.
    Alpha Prefix
    Three characters preceding the subscriber identification number on Blue Cross Blue Shield ID cards required for routing claims. It identifies the member's Blue Cross Blue Shield Plan or national account.
    ambulatory care facility (ACF)
    A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.
    ancillary services
    Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy and occupational therapy, used to support diagnosis and treatment of a patient's condition.
    annual and lifetime maximum benefit amounts
    Maximum dollar amounts set by MCOs that limit the total amount the plan must pay for all healthcare services provided to a subscriber per year or in his/her lifetime.
  3. B

    behavioral healthcare
    The provision of mental health and chemical dependency (or substance abuse) services.
    Benchmarking
    A method of planning and implementing quality management programs that consists of identifying the best practices and best outcomes for a specific process and emulating the best practices to equal or surpass the best outcomes.
    BHI®
    See Blue Health Intelligence.
    Blue 365®
    Addresses the health and lifestyle needs of consumers through unique partnerships and experiences designed exclusively for Blue365 members. A value added discount program that provides Blue members with discounts and content on health and wellness, family care, financial services, and healthy travel .
    Blue Advocacy
    The policy and legistlative division of the Blue Cross and Blue Shield Association representing The Blue System's views on healthcare insurance, advocacy, and policies on Capitol Hill.
    Blue Health Intelligence®

    Provides greater healthcare transparency by delivering detail about healthcare trends and best practices, resulting in healthier lives and affordable access to safe and effective care. BHI brings together the healthcare experience of more than 54 million Blue Cross and Blue Shield members nationwide. Visit https://www.bluehealthintelligence.com/ today.

    Blue Surgical Safety Checklist℠ ("Checklist")
    A one-page tool that itemizes essential safety steps that surgical teams should perform at three key stages of surgery.
    BlueCard Access®
    A toll-free 800 number, 1-800-810-BLUE, you and members can use to locate providers in another Blue Cross or Blue Shield Plan's area. This number is useful when you need to refer the patient to a physician or healthcare facility in another location.
    BlueCard Eligibility®
    A toll-free 800 number, 1-800-676-BLUE, for providers to verify membership and coverage information on patients from other Blue Cross Blue Shield Plans. Calling BlueCard Eligibility will facilitate quicker payments.
    BlueCard®
    Enables members to receive healthcare services wherever they live or travel, nationally or internationally. BlueCard links participating healthcare providers and the independent Blue Cross and Blue Shield companies across the country through a single electronic network for claims processing and reimbursement .
    BlueCard® PPO
    A national program that offers members traveling or living outside of their Blue Cross Blue Shield Plan's area the PPO level of benefits when they obtain services from a physician or hospital designated as a PPO provider.
    BlueCard® PPO Member
    Carries an ID card with this identifier on it. Only members with this identifier can access the benefits of BlueCard PPO.
    BlueCard® PPO Network
    The network comprising those physicians, hospitals and other healthcare providers PPO members may elect to use to obtain the highest level of PPO benefits.
    BlueCard® PPO Provider
    A doctor, hospital or other healthcare entity enrolled in a network of designated PPO providers.
    BlueDistinction®
    A designation awarded by the Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality healthcare in the areas of: bariatric surgery, cardiac care, complex and rare cancers, knee and hip replacement , spine surgery and transplants. The designation is based on rigorous, evidence-based, objective selection criteria established with input from expert physicians and recommendations from medical organizations .
    BlueWorks®
    The annual BlueWorks Awards program is designed to advance that mission by recognizing the single Blue Cross and/or Blue Shield company that best demonstrates taking a leadership role in transforming the quality, affordability and delivery of care. BlueWorks entries are reviewed by the Harvard Medical School Department of Health Care Policy and independent judges from key medical societies for their innovation, scope, approach and impact on healthcare delivery in Blue companies' local markets.
  4. C

    Call abandonment rate
    A measure of how often members hang up before receiving assistance when they make telephone calls to a company and are put on hold.
    claim
    An itemized statement of healthcare services and their costs provided by a hospital, physician's office or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
    claim form

    An application for payment of benefits under a health plan. International claim forms are located here. For other claim forms, please see your local Blue Cross and Blue Shield companies.

    claims investigation
    The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.
    clinic model
    See consolidated medical group.
    clinic without walls
    See group practice without walls.
    clinical practice guideline
    A utilization and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case.
    CMP
    See competitive medical plan.
    COBRA
    See Consolidated Omnibus Budget Reconciliation Act.
    coding errors
    Documentation errors in which a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.
    Coinsurance
    A provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 percent. Any additional costs are paid by the member out of pocket.
    contract management system
    An information system that incorporates membership data and provider reimbursement arrangements and analyzes transactions according to contract rules.
    coordinated care plans (CCPs)
    The Medicare+Choice delivery option that includes HMOs (with or without a point-of-service component), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs).
    copayment
    A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered. .
  5. D

    Deductible
    A flat amount the member must pay before the insurer will make any benefit payments.
    dental health maintenance organization (DHMO)

    An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

    dental point of service (dental POS) option

    A dental service plan that allows a member to use either a DHMO network dentist or to seek care from a dentist not in the HMO network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

    dental PPO

    See dental preferred provider organization. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

    dental preferred provider organization (dental PPO)

    An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

    DHMO

    See dental health maintenance organization. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

    Direct Care Provider
    An individual or organization that offers care directly to the member. The direct care provider is in the same physical location as the member and offers care to patients from within the local Plan's service area Some examples are: (1) a provider who physically examines the patient, (2) a lab that performs the blood draw from a patient, or (3) a technician who fits a prosthetic limb to the patient. The direct care provider should file claims to the local Blue Plan.
    disease management
    A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.
    disease state management
    See disease management.
    drug utilization review (DUR)
    A review program that evaluates whether drugs are being used safely, effectively, and appropriately.
  6. E

    electronic medical record (EMR)
    A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record.
    EMR
    See electronic medical record. .
    ERISA
    See Employee Retirement Income Security Act.
  7. F

    Federal Employee Health Benefits Program (FEHBP)
    A voluntary health insurance program for federal employees, retirees, and their dependents and survivors.
    fee schedule
    The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum or capped fee.
    fee-for-service (FFS) payment system
    A benefit payment system in which an insurer reimburses the group member or pays the provider directly for each covered medical expense after the expense has been incurred.
    Flexible Spending Account (FSA)
    Allows members to use pre-tax dollars for certain eligible medical and dependent care expenses. Members fund their FSAs with contributions that come out of their paycheck.
    formulary
    A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that are to be used by an MCO's providers in prescribing medications.
  8. G

    Good Health Club℠
    The Good Health Club promotes healthy choices and behaviors in children through fun, effective, age-appropriate communications. The Good Health Club uses a group of animated characters to teach kids to: Eat 5 servings of fruits and veggies every single day, limit screen time to 2 hours or less, get at least 1 hour of physical activity and limit sweetened drinks to 0.
    group model HMO
    An HMO that contracts with a multi-specialty group of physicians who are employees of the group practice. Also known as a group practice model HMO.
  9. H

    Health Insurance Portability and Accountability Act (HIPAA)
    A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies, and managed care organizations must satisfy in order to provide health insurance coverage in the individual and group healthcare markets.
    health maintenance organization (HMO)
    A healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.
    health promotion programs
    Preventive care programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as wellness programs.
    Health Reimbursement Arrangements (HRA)
    Accounts that employers can establish for employees to reimburse a portion of their eligible family members' out-of-pocket medical expenses, such as deductibles, coinsurance and pharmacy expenses.
    Health Savings Account (HSA)
    Allows members to save money into tax-advantaged accounts. Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free.
    HIPAA
    See Health Insurance Portability and Accountability Act.
    HMO
    See health maintenance organization.
    Hold Harmless
    An agreement with a provider not to bill the subscriber for any difference between billed charges for covered services (excluding coinsurance) and the amount the provider has contractually agreed with a BCBS Plan as full payment for those services.
    hospice care
    A set of specialized healthcare services that provide support to terminally ill patients and their families.
  10. I

    immunization programs
    Preventive care programs designed to monitor and promote the administration of vaccines to guard against childhood illnesses, such as chicken pox, mumps, and measles, and adult illnesses, such as pneumonia and influenza.
    Indemnity and Traditional Insurance
    Traditional insurance provides members with the most freedom of choice, and offers the most control over your healthcare. Traditional insurance, also known as Indemnity or Fee-for-Service, allows members to select any healthcare provider However, benefits are maximized when using a participating Blue Cross and Blue Shield company.
    Indirect Care, Support and Remote Provider (National Provider)
    An individual or organization that offers care to patients from outside the local Plan's service area. Services may be provided from a single site or from multiple locations The provider of service is the one who files a claim for a service supplied to the member. BlueCard applies if the provider of service is outside the member's Blue Plan's service area and does not contract with the member's Plan. The member's location at the time of service is irrelevant. Often the patient and the indirect care provider are in different physical locations.
  11. L

    large group
    A large pool of individuals for which health coverage is provided by the group sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number of members, depending on the MCO.
  12. M

    managed care
    The integration of both the financing and delivery of health-care within a system that seeks to manage the accessibility, cost and quality of that care.
    managed dental care
    Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.
    MCO
    See managed care organization.
    Medicaid
    A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.
    medical advisory committee
    The MCO committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation, and changes in authorization procedures, reviews data regarding new medical technology and examines proposed medical policies.
    medical director
    The health plan physician executive who is responsible for the quality and cost-effectiveness of the medical care delivered by the plan's providers. Also known as a chief medical officer.
    medical group practice
    See consolidated medical group.
    medical underwriting
    The evaluation of health questionnaires submitted by all proposed plan members to determine the insurability of the group.
    Medicare
    A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.
    Medicare Part A
    The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.
    Medicare Part B
    The Medicare component that provides benefits to cover the costs of physicians' professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home or an insured's home.
    Medicare SELECT
    A Medicare supplement that uses a preferred provider organization to supplement Medicare Part B coverage.
    Medicare supplement
    A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.
    Medigap policies
    Individual medical expense insurance policies sold by state-licensed private insurance companies.
    member services
    The broad range of activities that an MCO and its employees undertake to support the delivery of the promised benefits to members and to keep members satisfied with the company.
    MHS
    See Military Health System.
    MSO
    See Management Services Organization.
    mutual company
    A company that is owned by its members or policyowners.
    My Blue Community℠
    Online community that empowers members to make informed appropriate health choices based on either experiences from other healthcare consumers with similar circum?stances or expert advice.
  13. N

    National Account
    Employer group that has offices or branches in more than one location, but offers uniform coverage of benefits to all of its employees.
    National Walk@Lunch Day®

    An extension of the WalkingWorks® program -- helps people incorporate physical activity into their work day and encourages them to increase their daily physical activity by walking at lunch.

    network model HMO
    An HMO that contracts with more than one group practice of physicians or specialty groups.
  14. O

    Other Party Liability (OPL)
    A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions. Includes coordination of benefits, Workers' Compensation, subrogation and no-fault auto insurance.
    out-of-pocket maximums
    Dollar amounts set by MCOs that limit the amount a member has to pay out of his/her own pocket for particular healthcare services during a particular time period.
    outpatient care
    Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
  15. P

    PACE
    See Programs of All-inclusive Care for the Elderly.
    parent company
    A company that owns another company.
    Patient Centered Medical Home
    The PCMH is a model of healthcare based on an ongoing, personal relationship between a patient, doctor and the patient's care team. Whatever the medical needs ? primary or secondary, preventive care, acute care, chronic care, or end-of-life care ? the patient has a medical "home"; a single, trusted doctor and care team, through which continuous, comprehensive and integrated care is provided.
    PCCM
    See primary care case manager.
    PCMH
    See Patient-centered medical home.
    PCP
    See primary care provider.
    personal care physician
    See primary care provider.
    pharmaceutical cards
    Identification cards issued by a pharmacy benefit management plan to plan members. These cards assist PBMs in processing and tracking pharmaceutical claims Also known as drug cards or prescription cards.
    PHO
    See physician-hospital organization.
    Plan
    Refers to any Blue Cross and/or Blue Shield Plan.
    Point of Service (POS)
    A healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross and Blue Shield Plan?s network or seek medical care outside of the network.
    pooling
    The practice of underwriting a number of small groups as if they constituted one large group.
    PPO
    See preferred provider organization.
    pre-existing condition
    In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.
    preadmission testing
    A utilization management technique that requires plan members who are scheduled for inpatient care to have preliminary tests, such as X-rays and laboratory tests, performed on an outpatient basis prior to admission. .
    precertification
    A utilization management technique that requires a plan member or the physician in charge of the member's care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.
    prepaid care
    Healthcare services provided to an HMO member in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.
    prescription benefit management plan
    See pharmacy benefit management plan. ?See pharmaceutical cards.
    primary care
    General medical care that is provided directly to a patient without referral from another physician. It is focused on preventive care and the treatment of routine injuries and illnesses.
    primary care physician
    See primary care provider.
    primary source verification
    A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.
    prior authorization
    In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review See also precertification.
    prospective review
    The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented.
  16. R

    RVS
    See relative value scale.
  17. S

    screening programs
    Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem. .
    Second Opinion
    a television series that features panels of doctors, patients and related experts tackling real-life complex medical cases.
    small group
    Although each MCO's size limit may vary, generally a group composed of?two to 99 members for which health coverage is provided by the group sponsor.
    specialty HMO
    See specialty health maintenance organization.
    specialty services
    Healthcare services that are generally considered outside standard medical-surgical services because of the specialized knowledge required for service delivery and management.
    standard of care
    A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness or clinical circumstance.
    State Children's Health Insurance Program (SCHIP)
    A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.
  18. T

    Technology Evaluation Center
    Pioneered the development of scientific criteria for assessing medical technologies through comprehensive reviews of clinical evidence. Assessments provide objective information to those who deliver and manage medical care The assessments are based on clinical and scientific evidence and evaluate whether a technology improves health outcomes.
    termination with cause
    A contract provision, included in all standard provider contracts, that allows either the MCO or the provider to terminate the contract when the other party does not live up to its contractual obligations.
    termination without cause
    A contract provision that allows either the MCO or the provider to terminate the contract without providing a reason or offering an appeals process.
  19. U

    unbundling
    A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code for the entire procedure. The process of identifying and classifying the risk represented by an individual or group.
    underwriting manual
    A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.
    URO
    See utilization review organization.
    utilization review (UR)
    An evaluation of the medical necessity, appropriateness and cost-effectiveness of healthcare services and treatment plans for a given patient. .
  20. W

    WalkingWorks®

    Created by the Blue Cross and Blue Shield Association to help Blue Cross and Blue Shield companies motivate many of their more than 105 million members to integrate more walking into every day by tracking their steps via a walking log.