Glossary of Health Insurance Terms
As you explore our site, you may come across an unfamiliar word or term. We've developed a glossary of health care terms we hope will help you.
Select one of the following letters to take you to the part of the alphabet that applies.
Calendar Year - The period between January 1 and December 31 of any given year.
CAP - See "Competitive Allowance Program."
CAP Provider - A health care provider who has entered into a contract with BCBSKS. This provider has agreed to submit all claims and to accept our maximum allowable payment -MAP amount as payment in full, looking to the patient for only deductible, coinsurance, copayments, member contract indemnified payment limitation balances and non-covered service amounts. BCBSKS, in turn, will pay the provider directly and in a timely manner.
Capitation - A per member, monthly payment to a PCP, that covers contracted services. A PCP agrees specified services to pla members for this fixed, predetermined payment for a specified length of time, regardless of how many times the member uses the services.
Carrier - Any entity that underwrites or administers health insurance. This may be a government agency, a Blue Plan, a mutual company, a commercial insurer, or a company that contracts with a governmental agency. See "Medicare Part B Carrier."
Carry-over - Some major medical patient contracts allow charges incurred during the last three months of the patient's benefit period -calendar or contract/anniversary year to be applied to the deductible for the next benefit period.
Carve out - The method used to determine the benefits that are paid under a patient's contract when Medicare Part A, Medicare Part B or a liability insurer are primary and the patient has benefits that correspond to the basic benefits for all members of the patient's group. BCBSKS will compare Medicare's coverage and reimbursement to their coverage and reimbursement and will make additional payments as appropriate.
Carve out - To separately purchase services that are typically part of a managed care package. For example the HMO may "care out" the vision care benefit and select a specialized vendor to supply these services on a stand-alone basis.
Case Management - A voluntary program for the direction of the care for chronic diseases, severe injuries and catastrophic illnesses by a team of professionals who can advise the patient and physician about cost effective treatments and efficient uses of benefits. It is a program that assists the patient and family with complex health care decisions, with no additional cost to the patient for the service.
CAT/CT Scan - Computed axial tomography.
CCN - See "Claim Control Number."
Centers for Medicare & Medicaid Services -CMS - The division of Health and Human Services in the Federal Government that oversees the Medicare and Medicaid programs. CMS was formerly known as the Health Care Financing Administration (HCFA).
Certificate Number - A series of numbers and alpha characters which are unique to each member/member -patient contract. This series of numbers and alpha characters identify the member, their spouse and dependent children in our computer system. This is also referred to as "Identification Number."
Certificate of Medical Necessity -CMN - The form used by an attending physician to attest to the medical need of home medical equipment -HME or service.
Charge Comparison Report - A yearly report available to contracting providers that compares the actual charge to be made on certain services to the maximum allowable payment -MAP and what the provider write-off -if any will be.
Charges - The amount of money that a provider bills for a given service-s.
Choice Care - A rider to the patient's basic health insurance contract. A benefit option offered by BCBSKS to members, where the patient is required to obtain hospital services from a designated Choice Care hospital in order to obtain full benefits under the terms of their contract.
ClaimCheck - The auditing software system used by BCBSKS to ensure consistent adjudication of services. This system is sometimes referred to as GMIS.
Claim Control Number -CCN - The unique numeric sequence that identifies a specific billing to BCBSKS for medical services rendered.
Claims Review - The method by which patients' services are examined prior to payment. The purpose of this is to validate the medical appropriateness of the service and to be sure that the cost of the service is not excessive.
Clean Claim - A claim not requiring additional information and/or handling to process immediately through the claims computer system.
Clearinghouse - A system that allows electronic claims -paperless submission through a single source for most payors. The system transfers the claims to the appropriate payor electronically.
Clinical Outcome - The state of a patient's health after receiving medical care.
CMES - See "Contracting Medical Equipment Suppliers".
CMN - See "Certificate of Medical Necessity."
CMS - See "Centers for Medicare & Medicaid Services."
CMS Assigned Procedure Codes - This is the second level of codes in Centers for Medicare and Medicaid Services Common Procedure Coding System. These codes and their nomenclature are assigned by Health Care Financing Administration.
COB - Stands for "Coordination of Benefits" and is now called Other Party Liability or OPL. See "Other Party Liability"
COBRA - See "Consolidated Omnibus Budget Reconciliation Act of 1985."
Cognitive Therapy - A service provided to retain or enhance information processing due to brain damage or brain dysfunction which alters the way in which a person perceives or responds. These services include, but are not limited to, treatment of memory loss, problem solving difficulties, short attention span and an inability to scan visually. These services are usually non-covered.
Coinsurance - The fixed percentage of the allowed charge that the patient's contract denotes as the patient's responsibility. These amounts are collectible at the time of service by contracting providers. Coinsurance amounts are generally 10, 20, or 50 percent.
Coinsurance Maximum - The specified dollar amount of patient out-of-pocket expense for coinsurance that has to be met before BCBSKS will begin to pay 100 percent of the allowed charge for covered services.
Common Pay Provider Number - A unique numeric identifier that allows several individual provider numbers to generate one common remittance advice and check from BCBSKS using one common federal identification number for the group. See "Individual Provider Number" and "Claims Filing."
Competitive Allowance Program -CAP - The methodology of reimbursement of, and contracting with, health care providers that BCBSKS implemented January 1, 1984. This network of providers is used for our traditional member -patient benefit programs.
Complementary Coverage - A patient contract that pays the deductible and coinsurance of Medicare covered services. Some contracts pay less, and others may pay more than just these amounts.
Compliance - Refers to capability of voluntarily following the written instructions for using a drug or other prescribed treatment regimen. This can also refer to the provider's willingness to follow BCBSKS contract and policy memos.
Comprehensive Major Medical - The patient has a set amount of out-of-pocket expense -deductible, coinsurance and/or copayment before BCBSKS begins to reimburse for covered services at 100 percent of the MAP under the patient's benefit plan.
Computerized Patient Medical Record - An electronic system that enables providers to capture, store and communicate health care information.
Consolidated Omnibus Budget Reconciliation Act of 1985 -COBRA - All groups having 20 or more employees are required by federal law -under the provisions of COBRA to provide expanded conversion privileges to covered employees and their dependents who are no longer eligible for group coverage for a specified amount of time. Unlike other laws, these provisions apply to groups with self-insurance programs.
Consultant - A practicing provider of a given specialty that BCBSKS contracts with to review claims of the same specialty.
Content of Service - All of the expenses -procedures, tests, overhead, materials, etc. that are included in the allowance for any given service. See "Bundling" and "Unbundling."
Contract - See "Contracting Provider Agreement."
Contract Exclusion -Patient Contract - An item or services specifically defined as non-covered in the patient's BCBSKS contract. These are the patient's financial responsibility.
Contract Indemnified Payment Limitation Balances - The amount over and above the set amount identified in the patient's BCBSKS contract for a given service or item. This balance is the patient's financial responsibility.
Contract Period - See "Benefit Period" and "Contract/Anniversary Year."
Contract/Anniversary Year - The period of time that an agreement is in effect. For a provider, it is usually a calendar year. This period for patient contracts may be a calendar year or a year from the effective date of patient enrollment such as April 1, 1999 through March 31, 2000.
Contracting - See "Contracting Provider."
Contracting Provider - A health care provider who has entered into an agreement with BCBSKS. The provider agrees to submit all claims and accept what BCBSKS allows, bill the patient for only the coinsurance, copayment, deductible, member/member -patient contract indemnified payment limitation balance and non-covered service amounts.
Contracting Provider Agreement - The contract entered into by the contracting provider and BCBSKS. See "Contracting Provider."
Control Plan - A Blue Cross and Blue Shield Plan that has entered into an agreement to administer a National Account. The National Account is usually headquartered in the Control Plan area. All other Plans that are involved in processing claims for the National Account are referred to as National Account Participating Plans.
Convalescent Care - Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.
Coordination of Benefits - See "Other Party Liability.
Copay, Copayment - A specific set amount patients are required by their contract to pay on a given service. These amounts are not percentages of an allowance -coinsurance, but are a flat fee per the service. An example would be a $15 copay on office calls. A copayment does not accumulate towards a specified maximum.
Cosmetic – means procedures and related services performed to reshape structures of the body in order to alter the individual’s appearance. Cosmetic services or supplies are usually patient contract exclusions. Some member contracts may offer limited coverage for cosmetic or reconstructive services if related to an accident, congenital abnormalities or when performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. Contact BCBSKS for specific coverage information.
Cost Containment - Strategies used to limit or control health care costs that do not sacrifice the quality of care.
Cost Sharing - Financing arrangement whereby the patient must pay some of the bill to receive care.
Covered Person - An individual who meets a health plan's eligibility requirements and for whom premium payments are paid for specified benefits of the contract between the insurance carrier and a contract holder.
Covered Service - A service or supply for which BCBSKS will make reimbursement as outlined in the patient's contract.
CPR - Cardiopulmonary resuscitation.
CPT - See "Current Procedural Terminology" definition in this section of the manual.
CQI - Continuous quality improvement.
Credentialing - The process by which BCBSKS's Blue Select program ensure that the PCPs, referral specialists and consultants meet our quality of care standards.
Credentialing Appeals - The procedures established for providers to have our credentialing decisions re-examined.
Cross - See "Blue Cross of Kansas" and "Anthem Blue Cross and Blue Shield, Inc."
CSC - See "Customer Service Center."
Current Procedural Terminology -CPT - A published listing of procedure codes and nomenclature developed by the American Medical Association for reporting medical services. This is the first level of the Health Care Financing Administration Common Procedure Coding System.
Custodial Care - Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.
Custom-Made - Medical items that are not bought over the counter -i.e. custom stockings, customer wheelchair seating systems. These items cannot be used by anyone but the patient for whom they are made.
Customary Charge - See "Usual, Customary and Reasonable."
Customer Service Center -CSC - The department at BCBSKS that responds to telephone and written inquiries from providers and patients regarding claims processing and benefits.