Glossary of Health Insurance Terms

See "Physician Profiling System."

A system of reporting medical services performed that is used nationally. The system consists of three levels of codes: Level 1 is the AMA's CPT codes; Level 2 is HCFA assigned codes and nomenclature; and Level 3 is the local codes and nomenclature assigned by each Medicare Carrier or the insurance carrier and is unique to them. This system is updated annually.

The national uniform claim form used to identify and request reimbursement for medical services provided to patients.

See "HCFA Common Procedure Coding System."

See "History, Exam, Assessment and Layout."

A comprehensive package of benefits identified for specified chronic diseases and intended to improve long-term patient outcomes.

This is the Kennedy-Kassebaum Act that intends to provide patients the ability to take insurance coverage with them between employment. This law also prevents insurance companies from excluding patients with pre-existing conditions. There are other provisions of the law. The ones cited here are two that affect providers and BCBSKS.

An entity that makes available medical care services for members -patients at a predetermined, usually global periodic reimbursement rate, to the PCP. HMOs require a PCP to direct the care of the member.

The subcontractor that BCBSKS uses to pre-certify psychiatric care.

A report card developed by NCQA for employers and consumers to use to compare managed care plans to one another.

A form when completed by the applicant that offers health history information and is used to determine the premium and establish coverage.

See "Health Plan Employer Data and Information Set."

See "Health Insurance Portability and Accountability Act of 1996."

An accepted approach to patient processing and recordkeeping in a physician's office. See "Medical Recordkeeping."

Home infusion therapy.

See "Home Medical Equipment."

See "Health Maintenance Organization."

See "Health Management Strategies."

A piece of equipment that replaces a malfunctioning body part. It must be able to withstand repeated use and not be useful if the body part were functioning properly. The item must be prescribed for, in most cases, by the patient's attending physician. Also referred to as Durable Medical Equipment (DME).

A Blue Cross and Blue Shield Plan that is part of the BlueCard Program which administers the benefits for services incurred by their member in another Blue Cross and Blue Shield Plan's area.

A practitioner who follows the philosophy that “like cures like.” These practitioners usually try to match a person’s personality, habits, and symptoms with a remedy. The remedy is usually a highly diluted substance that is believed to create the same symptoms that an illness has created in the consumer. These services are non-covered under BCBSKS.

A Blue Cross and Blue Shield Plan that is part of the BlueCard program which makes payments for services rendered by a provider in their Plan area for a patient from another Plan.