Glossary of Health Insurance Terms

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.

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.

Strategies used to limit or control healthcare costs that do not sacrifice the quality of care.

Financing arrangement whereby the patient must pay some of the bill to receive care.

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.

A service or supply for which BCBSKS will make reimbursement as outlined in the patient's contract.

Cardiopulmonary resuscitation.

See "Current Procedural Terminology."

Continuous quality improvement.

The process by which BCBSKS's Blue Select program ensure that the PCPs, referral specialists and consultants meet our quality of care standards.

The procedures established for providers to have our credentialing decisions re-examined.

See "Blue Cross of Kansas" and "Anthem Blue Cross and Blue Shield, Inc."

See "Customer Service Center."

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.

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

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.

See "Usual, customary and reasonable."

The department at BCBSKS that responds to telephone and written inquiries from providers and patients regarding claims processing and benefits.

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.