Glossary of Health Insurance Terms

The period between Jan. 1 and Dec. 31 of any given year.

See "Competitive Allowance Program."

A healthcare 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.

A per member, monthly payment to a PCP, that covers contracted services. A PCP agrees specified services to pay members for this fixed, predetermined payment for a specified length of time, regardless of how many times the member uses the services.

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."

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.

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.

or

To separately purchase services that are typically part of a managed care package. For example the HMO may "carve out" the vision care benefit and select a specialized vendor to supply these services on a stand-alone basis.

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 healthcare decisions, with no additional cost to the patient for the service.

Computed axial tomography.

See "Claim Control Number."

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).

The form used by an attending physician to attest to the medical need of home medical equipment -HME or service.

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.

The amount of money that a provider bills for a given service(s).

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.

The unique numeric sequence that identifies a specific billing to BCBSKS for medical services rendered.

The auditing software system used by BCBSKS to ensure consistent adjudication of services. This system is sometimes referred to as GMIS.

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.

A claim not requiring additional information and/or handling to process immediately through the claims computer system.

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.

The state of a patient's health after receiving medical care.

See "Certificate of Medical Necessity."

See "Centers for Medicare & Medicaid Services."

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.

Stands for "Coordination of Benefits" and is now called Other Party Liability or OPL. See "Other Party Liability"

See "Consolidated Omnibus Budget Reconciliation Act of 1985."

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.

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.

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.

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."

The methodology of reimbursement of, and contracting with, healthcare providers that BCBSKS implemented January 1, 1984. This network of providers is used for our traditional member -patient benefit programs.

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.

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.

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.

An electronic system that enables providers to capture, store and communicate healthcare information.

Non-public information that includes strategic and/or competitively sensitive information including, but not limited to, BCBSKS, the Blue Cross Blue Shield Association, or other BCBS company trade secrets, policies, procedures, data and processes.

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.

A practicing provider of a given specialty that BCBSKS contracts with to review claims of the same specialty.

All of the expenses -procedures, tests, overhead, materials, etc. that are included in the allowance for any given service. See "Bundling" and "Unbundling."

See "Contracting Provider Agreement."

An item or services specifically defined as non-covered in the patient's BCBSKS contract. These are the patient's financial responsibility.

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.

See "Benefit period" and "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.

See "Contracting Provider."

A healthcare 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.

The contract entered into by the contracting provider and BCBSKS. See "Contracting provider."

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.

Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.

See "Other Party Liability."