The Blue Cross Blue Shield Association is an association of 36 independent, locally operated Blue Cross and/or Blue Shield companies.

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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 (techniques to reduce costs and improve quality of heallthcare) to 24-hour coverage.

A

accountable care organization (ACO)

A group of healthcare providers that agrees to deliver coordinated care, meeting performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations.

accreditation

A process in which a healthcare organization undergoes an evaluation 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.

Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (commonly called the ACA) was signed into law in 2010 to address access, quality and cost in the healthcare industry. The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” refers to the final, amended version of the law.

alpha prefix

The three characters preceding the subscriber identification number on BCBS member ID cards. It identifies the member's Blue Cross Blue Shield company or national account in order to properly route the claim.

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.

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 (managed care organizations) that limit the total amount the plan must pay for all healthcare services provided to a subscriber per year or in his/her lifetime.

ASC – Ambulatory Surgery/Surgical Center

A free-standing center that performs various types of surgery.

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.

Blue Cross Blue Shield AxisSM

A national data capability derived from Blue Cross Blue Shield companies' collective provider networks and membership.

Blue Distinction©

Blue Cross Blue Shield awards this designation to medical facilities that have demonstrated expertise in delivering quality healthcare in the areas of: bariatric surgery, cardiac care, complex and rare cancers, spine surgery, transplants and knee and hip replacement. The designation is based on evidence-based, objective selection criteria established with input from expert physicians and recommendations from medical organizations .

Blue Health Intelligence (BHI)

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.

Blue365©

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 Cross and Blue Shield members with discounts and content on health and wellness, family care, financial services and healthy travel .

BlueCard Access©

A toll-free number, 1-800-810-BLUE, that members can use to locate providers in another Blue Cross Blue Shield company's area. BlueCard Access© assists members who need a referral to a physician or healthcare facility in another location.

BlueCard Eligibility©

A toll-free number, 1-800-676-BLUE, for healthcare providers to verify Blue Cross Blue Shield membership and coverage information for patients. Calling BlueCard Eligibility will facilitate efficient payment for the provider.

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 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 (preferred provider organization) 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.

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.

claims investigation

The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.

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.

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 (CCP)

The Medicare+Choice delivery option that includes health maintenance organizations, or 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.

D

deductible

A flat amount the member must pay before the insurer will make any benefit payments. The deductible is usually a set amount or percentage determined by the member’s contract and is set for a given period of time.

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 Blue Shield company.

dental point of service (dental POS) option

A dental service plan that allows a member to use either a dental health maintenance organizations (DHMO) network dentist or to seek care from a dentist not in the health maintenance organization's (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 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 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 Cross Blue Shield company.

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.

drug utilization review (DUR)

A review program that evaluates whether drugs are being used safely, effectively and appropriately.

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.

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 (managed care organization) 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 (managed care organization) providers in prescribing medications.

G

group model HMO

A health maintenance organization (HMO) that contracts with a group of physicians with multiple specialties who are employees of the group practice. Also known as a group practice model HMO.

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 to individuals and groups.

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

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 preventive care programs or 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.

Hold Harmless Agreement

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 Blue Cross Blue Shield company as full payment for those services.

hospice care

A set of specialized healthcare services that provide support to terminally ill patients and their families.

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, as well as adult illnesses, such as pneumonia and influenza.

Indemnity and Traditional Insurance

Traditional insurance, also known as Indemnity or Fee-for-Service, allows members to select any healthcare provider for services. Traditional insurance offers the most freedom of choice and control over healthcare, but benefits are maximized when using a participating Blue Cross 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 Cross Blue Shield 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.

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 managed care organization.

M

managed care

The integration of financing and delivery of healthcare 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 (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and changes in authorization procedures. Medical advisory committees also review data regarding new medical technology and examine 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 underwriting

The evaluation of health questionnaires submitted by all proposed plan members to determine the overall 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 (PPO) 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 ensure member satisfaction.

mutual company

A company that is owned by its members or policyowners.

N

National Account

An employer that has offices or branches in more than one location, but offers uniform healthcare coverage of benefits to all of its employees.

National Walk@Lunch Day

An extension of the Blue Cross Blue Shield WalkingWorks® program, this event helps people incorporate physical activity into their workday and encourages them to increase their daily physical activity by walking at lunch.

network model HMO

A health maintenance organization (HMO) that contracts with multiple group practices of physicians or specialty groups.

O

Other Party Liability (OPL)

A cost containment program that recovers money for healthcare 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 (managed care organizations) 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.

P

parent company

A company that owns another company.

pharmaceutical cards

Identification cards issued by a pharmacy benefit management plan (PBM) to plan members. These cards assist PBMs in processing and tracking pharmaceutical claims. Also known as drug cards or prescription cards.

PHI - Protected Health Information

Information that relates to an individual's past, present, or future physical or mental health or condition, or the past, present, or future payment for the provision of health care to an individual, including demographic information, received from or on behalf of a health care provider, health plan, clearinghouse, or employer, which either identifies the individual or could be reasonably used to identify the individual. It includes such information contained in any form or medium (electronic, paper, oral, etc.).

PII – Personally Identifiable Information

An individual's first name or first initial and last name in combination with any one, or more, of the following: (1) Social Security number; (2) driver's license number or state identification card number; or (3) account number, credit or debit card number, in combination with any required security code, access code or password that would permit access to an individual's financial account. PII does not include publicly available information that is lawfully made available to the general public from federal, state or local government records or widely distributed media. PII, as used in these Inter-Plan Programs Policies and Provisions, may have other meanings as assigned by various state laws related to data security breach notification.

Plan

Refers to any Blue Cross and/or Blue Shield Plan.

point-of-service (POS) plan

A type of Health Benefit Plan that allows members to go outside the network for non-emergency care, but may result in a lower level of benefits being paid by the Health Benefit Plan.

pooling

The practice of an insurance company underwriting a number of small groups as if they constituted one large group.

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 health insurance 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 healthcare insurance 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 a health maintenance organization (HMO) member in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.

prescription 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 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.

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 the size limit of each MCO (managed care organization) may vary, a small group generally refers to a group containing at least two and less than a hundred 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)

Established by the Balanced Budget Act, this program is designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

T

Technology Evaluation Center

Founded in 1985 by the Blue Cross Blue Shield Association, the Technology Evaluation Center pioneered the development of scientific criteria for assessing medical technologies through objective, comprehensive reviews of clinical evidence. Its mission is to provide health care decision makers with timely, rigorous, credible assessments that synthesize the available evidence on the diagnosis, treatment, management and prevention of disease.

telehealth

The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.

termination with cause

A contract provision, included in all standard provider contracts, that allows either the MCO (managed care organization) 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 (managed care organization) or the provider to terminate the contract without providing a reason or offering an appeals process.

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.

utilization review (UR)

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

W

WalkingWorks©

WalkingWorks© is a physical fitness and wellness program developed by Blue Cross Blue Shield, in cooperation with the President’s Council of Physical Fitness and Sports, to help BCBS members reach fitness goals while improving your overall health. The website lets members log daily activities and track progress over time.