Glossary

The amount a healthcare provider actually bills a patient. You may have seen the phrase, "The actual charge may be different from the allowable charge." This means BCBSKS may only cover a portion of what a doctor charges a member. For example, a doctor bills $40 for an office visit. This is the actual charge. But BCBSKS may only allow $35 for an office visit. This is the allowable charge.

Group that contracts with BCBSKS to provide administrative and claims payment services according to the group's coverage criteria. The group assumes the risk for the cost of services the subscribers receive, rather than paying premiums. The group can also purchase stop-loss insurance from BCBSKS that limits such risk.

The State of Kansas department in Social and Rehabilitation Services that is responsible for the certification of Outpatient Substance Abuse Facilities.

The maximum amount BCBSKS will pay for a covered service. You may have seen the phrase, "The actual charge may be different from the allowable charge." This means BCBSKS may only cover a portion of what a doctor charges a member. For example, a doctor bills $40 for an office visit. This is the actual charge. But BCBSKS may only allow $35 for an office visit. This is the allowable charge.

Maximum amount on which payment is based for covered healthcare services. This may be called "eligible expense," "payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.

The anniversary of when the coverage was effective.

The 12-month period based on the group anniversary month.

A request for your health insurer or plan to review a decision or grievance again.

A method of payment where the insurance premium is deducted directly from an account at a financial institution on a monthly basis.