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

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.

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.

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.

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 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.

drug utilization review (DUR)

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

F

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.

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 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.

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.

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.

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.

N

network model HMO

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

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

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.

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.

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.

S

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.

T

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

utilization review (UR)

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