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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

    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. C

    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.
    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.
    contract management system
    An information system that incorporates membership data and provider reimbursement arrangements and analyzes transactions according to contract rules.
    copayment
    A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered. .
  4. D

    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.

    drug utilization review (DUR)
    A review program that evaluates whether drugs are being used safely, effectively, and appropriately.
  5. F

    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.
    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.
  6. G

    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.
  7. H

    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.
    hospice care
    A set of specialized healthcare services that provide support to terminally ill patients and their families.
  8. 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.
  9. 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.
  10. 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.
    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 group practice
    See consolidated medical 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.
  11. N

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

    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.
  13. P

    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.
    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.
  14. S

    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.
  15. T

    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.
  16. U

    utilization review (UR)
    An evaluation of the medical necessity, appropriateness and cost-effectiveness of healthcare services and treatment plans for a given patient. .