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

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.

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.

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.

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.

F

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.

H

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 Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free.

M

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.

O

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

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.