Glossary of Health Insurance Terms

The month, day, year that a patient was born. This must match our records for the claim to process.

The month, day, year that a service was performed or an item was delivered.

Doctor of Chiropractic Medicine

A specified amount of out-of-pocket expense, a patient must pay in a benefit period before BCBSKS will begin reimbursement. These services must be submitted to BCBSKS so we may keep track of the expenses met. Deductible amounts are collectible at the time of service by a contracting provider.

Items or services that are added beyond the standard model and are not considered to be medically necessary.

From time to time, a patient may demand that items or services be provided when there is a question of medical necessity or coverage. The provider should have a waiver form signed. The waiver is kept in the patient's file. The modifier "GA" should be used with the procedure code on the claim.

A line item or entire claim that has been determined to have no benefit coverage due to patient or provider contract limits, duplicate service(s) already processed or duplicate coverage by another insurance carrier.

A person eligible for coverage under a benefits plan because of that person's relationship to the primary member. Spouses and children are often eligible for dependent coverage.

A person, entitled to health insurance, other than the person who holds the healthcare insurance policy. This is usually the spouse or child of the contract holding person.

Disease process identified by evaluation of patient's signs, symptoms, complaints, and test results.

See "International classification of diseases"

A payment methodology in which hospital procedures are rated in terms of cost and intensity of services delivered. A standard rate per procedure is derived from this scale, which is paid by the insurer, regardless of the cost to the hospital to provide that service.

A non-group member -patient who pays their insurance premium directly to BCBSKS, rather than an employer paying the premium to BCBSKS.

Any medical condition that results in major functional limitations that interfere with a patient's ability to perform normal activities of daily activity.

BCBSKS insurance coverage that pays after Medicare Part B has paid. This does not cover the Medicare Part A and Part B deductibles. It covers only the Medicare Part B 20 percent coinsurance amounts.

BCBSKS insurance coverage that pays after Medicare Part A and Part B have paid. This covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance and services received in foreign countries.

Non-payment or partial payment of services rendered. This may be for various reasons. It may be the service is non-covered under the patient's insurance contract.

A formalized plan to care for a patient with a chronic illness. The plan's goal is to help prevent recurrence of symptoms, prevent future need for medical resources and to maintain the highest possible quality of life. This approach utilizes roles played by pharmacy, case managers, care givers and family to obtain the best possible outcomes while helping to maintain overall lower costs. See "Healthcare management benefits."

See "Health care management benefits."

See "Durable Medical Equipment Regional Carrier."

Doctor of Osteopathic Medicine

See "Date of Birth."

See "Medical Recordkeeping."

Date of Death

See "Date of Service."

See "Diagnosis Related Groups."

This provision applies to covered group employees (or family members of the employee) who are eligible for benefits from another group healthcare plan. Duplication of benefits coordination is conducted to make sure members do not profit by receiving payment from more than one source.

See "Home Medical Equipment."

CMS Central Office, in Baltimore, has elected to contract with a limited number of entities to process home medical equipment for the Medicare Part B program. Vision correction hardware and home medical equipment provided in Kansas for Medicare Part B beneficiaries should be submitted to CIGNA -Connecticut General Life Insurance Company. If the provider has questions about this procedure, they should contact their Kansas Medicare Carrier or CIGNA directly.

See "Diagnosis."