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

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.

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.

ASC – Ambulatory Surgery/Surgical Center

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

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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.

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C

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.

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).

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D

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.

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.

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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.

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H

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.

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I

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.

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M

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.

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.

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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.

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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.

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P

parent company

A company that owns another company.

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.

pooling

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

prospective review

The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented.

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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.

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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.

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