Glossary

ASO Benefit description, non-group contract, insured group certificate or other coverage document that links the Primary Member to benefits.

Healthcare services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

A benefit your employer, union or other group sponsor provides to you to pay for your healthcare services.

A prepaid health plan or insurance program that offers the convenience and comprehensive coverage of a managed benefits program by working with a primary care physician for maximum benefits, but also allowing a member 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).

The person or entity to which the insurance contract has been issued is a member of BCBSKS and is entitled to vote in person or by proxy at meetings of policyholders.

An annual meeting of policyholders held on the second Thursday in May of each year at 8:30 a.m. at the corporation’s principal place of business at 1133 SW Topeka Blvd., Topeka, KS, or at such other place as the Chairman of the Board of Directors might designate in a notice of meeting given to policyholders. Printed notice shall be sufficient notification.

The process of deciding whether or not BCBSKS will cover a specific service. Check the health plan carefully. Certain procedures, like surgery, require pre-certification. This means the member needs to check with BCBSKS to see if the service is covered before it is received.

An injury or illness that is evident before the effective date of the contract. Many health plans do not cover pre-existing conditions. Or, they have a waiting period before the member can receive benefits for them. For example, you hurt your knee playing football a couple of years ago and had to have surgery. When you sign up for a new health plan, you'll have to list your knee injury as a pre-existing condition.

A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn't a promise your health insurance or plan will cover the cost.

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also "participating" providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

A network-based, managed care plan that allows the participant to choose any healthcare provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverages and lower deductibles.

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Health insurance or plan that helps pay for prescription drugs and medications.

Drugs and medications that by law require a prescription.

Medical and dental services aimed at early detection and intervention.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of healthcare services.

The person identified on the ASO benefit description, non-group contract, insured group certificate or other coverage document.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), healthcare professional or healthcare facility licensed, certified or accredited as required by state law.

The amount of money contracting healthcare providers deduct from their charge due to contracts between themselves and a health plan.