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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.

P

PA - Physician Assistant.

PA - Professional Association.

PAR - Participating or contracting provider.

Part A - See "Medicare Part A."

Part B - See "Medicare Part B."

Participating Plan - A Blue Cross and Blue Shield Plan that has agreed to provide coverage for a National Account.

Patient - See "Insured" and "Member."

PC - See "Professional Component."

PCP - See "Primary Care Physician."

PDR - See "Physician's Desk Reference."

Pended Claim - A bill for service-s that has been put on hold until additional information is obtained.

Performing Provider Number - See "Individual Provider Number."

Personal Injury Protection -PIP - Used for determination of benefits payable under the other party liability provision of the patient's contract when there has been a motor vehicle involvement.

PET - Positron emission tomography.

Physical Medicine Rider - The provision in the patient's contract that provides limited benefits for physical therapy, physical medicine modalities, occupational therapy, speech therapy, respiratory therapy, approved cardiac rehabilitation, pulmonary rehabilitation, and perceptual therapy. Physical medicine services by a chiropractor, occupational therapist, speech pathologist or physical therapist, such as cold packs, ultrasound, tests and measurements, treatments for speech disorder, etc. are usually applied to this benefit limit annually.

Physician's Desk Reference -PDR - A book listing drugs, their appropriate use and possible side-effects.

PIP - See "Personal Injury Protection."

Place of Service - The location where the service was performed.

Plan - See "Blue Plan."

Plan Area - The geographic jurisdiction of a specific Blue Cross and Blue Shield. See "Kansas Plan Area."

Plan of Treatment - See "Treatment Plan" and "Medical Recordkeeping."

Plan 65 Under Age 65 - BCBSKS insurance coverage, for those disabled, that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles and the Medicare Part B 20 percent coinsurance.

Plan 65 Over Age 65 - BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles and the Medicare Part B 20 percent coinsurance .

Plan 65 Benefit A - BCBSKS insurance coverage that pays after Medicare Part B. It does not cover the Medicare Part A or Part B deductibles. It covers only the Medicare Part B 20 percent coinsurance. This coverage also includes the coinsurance for the 61st through the 90th day of inpatient care.

Plan 65 Benefit C - BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance and limited coverage for services received in a foreign country.

Plan 65 Benefit F - BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance , limited coverage for services received in a foreign country and the amount in excess of the Medicare allowed charge on non-assigned claims.

Plan 65 Select Benefit C - BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance and limited coverage for services received in a foreign country. For hospital benefits to be paid the patient must seek care at a Plan 65 Select hospital.

Plan 65 Select Benefit F - BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance, limited coverage for services received in a foreign country and the amount in excess of the Medicare allowed charge on non-assigned claims. For hospital benefits to be paid the patient must seek care at a Plan 65 Select hospital.

Point of Service -POS - A prepaid health plan or insurance program, that offers the convenience and comprehensive coverage of a managed benefits program by working with a PCP for maximum benefits. It also allows the patient to self-refer at a lower payment level of benefits, as with the flexibility of a traditional benefits program. Sometimes referred to as Self-Referred Option -SRO. Blue Select is a POS type of contract.

POS - See "Point of Service" and "Place of Service."

Post-Payment Review - The procedure by which BCBSKS reviews and re-adjudicates -if appropriate claims that have already been processed.

PPO - See "Preferred Provider Organization."

PR - Professional Relations Department at BCBSKS. This department handles education of and problems for the providers who bill on the HCFA 1500 claim form.

PR - Provider Relations Department at BCBSKS. This department handles education of and problems for the providers who bill on the UB 92 claim form.

PR - Public Relations Department at BCBSKS. This department handles inquires from outside entities such as newspapers, television stations, radios etc.

PR Representative - The BCBSKS field representatives who provide a liaison between the health care provider community and BCBSKS. The representatives work in the Professional Relations and Provider Relations Departments. Those using this manual would work with the representatives in Professional Relations. The representatives in Provider Relations work with hospitals and are titled Provider Consultants.

Preauthorization - See "Predetermination."

Precertification - The formalized telephone procedure by which some services -i.e. hospital admissions are approved prior to being performed.

Predetermination - The procedure by which some services -i.e. air ambulance, customized wheelchairs, etc. may be approved prior to being performed or ordered. This is a service offered by BCBSKS to providers so the patient is aware of their financial responsibility prior to services being rendered or ordered. A letter or fax to CSC with a completed predetermination form will initiate the process.

Pre-Existing Condition - Any illness, symptoms, or complications of any illness that existed prior to the effective date of the patient's contract. If the patient has received an evaluation, diagnosis, or treatment for the illness, symptoms, or complications of any illness within a specified number of days immediately prior to the patient's contract effective date; the illness, symptoms, or complications of any illness will be considered pre-existing. See "Pre-Existing Rider" and "Pre-Existing Waiting Period."

Pre-Existing Rider - The provision in the patient's contract that excludes or limits coverage of a condition that was present prior to the effective date of the BCBSKS member contract. See "Pre-Existing Condition" and "Pre-Existing Waiting Period."

Pre-Existing Waiting Period - The time during which the patient contract prohibits coverage of a condition that was present prior to the effective date of that contract. This period of time is usually 240 or 270 continuous days before benefits are available for the condition. See "Pre-Existing Condition" and "Pre-Existing Rider.

Preferred Providers - Doctors, hospitals and other health care providers who contract to provide health care services to patients covered by a particular health insurance plan. As an example: BCBSKS' CAP network providers are the preferred providers the Blue Choice product.

Preferred Provider Organization - A group of doctors and/or businesses involved in health care services that have come together under a plan with specific guidelines and reimbursement amounts. As an example: BCBSKS' CAP network is the PPO Blue Choice.

Prepayment Review - The procedure by which BCBSKS adjudicates claims based on specific guidelines relative to a given provider, patient, or procedure before the claim reaches final disposition through regular processing. Usually these claims require medical records to be submitted with the claim.

Prescription - The order written by the attending physician relative to services, equipment or drugs to be dispensed.

Prescription Drugs - Medicines requiring the written dispensing and usage instructions of a medical doctor -MD or doctor of osteopathic medicine -DO, purchased through a pharmacy or the office of the MD/DO.

Primary Care Physician -PCP - The doctor of medicine or osteopathy, selected by the patient, who provides or coordinates all the patient's health care needs. These providers are sometimes referred to as gatekeepers. The PCP is usually the first provider a patient sees for care. The PCP usually treats the patient directly, refers the patient to a referral specialist -secondary care giver or admits the patient to a hospital.

Primary Carrier - See "Primary Insurance Carrier."

Primary Diagnosis - The main condition, illness, injury, symptom or patient complaint for which the patient is seen. This diagnosis is listed in the first diagnosis space on the claim form and may change from encounter to encounter.

Primary Insurance Carrier - The company or plan who has first responsibility to pay benefits when there is duplicate coverage.

Prior Approval - See "Predetermination" and "Precertification."

Prior Authorization - See "Predetermination and "Precertification."

Procedure Code - The five-digit numeric identifier of the service performed. See "HCFA Common Procedure Coding System."

Professional Component - The charge for a doctor examining, interpreting and expressing their opinion in a written report of an x-ray or lab test.

Profiling - See "Physician Profiling System."

Program Area - See "Enrollment Area."

Progress Notes - See "Subjective Objective Assessment and Plan Documentation" and "Medical Recordkeeping."

Pro-Ration - A patient contract provision whereby BCBSKS assumes only its proportionate share of liability when a patient has coverage through more than one insurance company. See "Subrogation."

Provider - An individual, institution, facility, group or organization qualified to give health care services to our members/members -patients.

Provider Agreement - See "Contracting Provider Agreement."

Provider Consultant - The BCBSKS field representative who provides a liaison between the health care facility community and BCBSKS. The representatives work in the Provider Relations Department. The providers bill on the UB 92 claim form.

Provider Contract - See "Contracting Provider Agreement."

Provider Discounts - The amount contracting deliverers of health care services agree to write off when signing contracts with certain networks.

Provider Number - See "Individual Provider Number" and "Group Provider Number."

Provider Profiling System - See "Physician Profiling System."

Psychiatric Limits - The yearly and/or lifetime total dollar amounts that the patient contract mandates. Substance abuse services are applied to these limits.

PT - See "RPT."