Glossary of Health Insurance Terms

The main condition, illness, injury, symptom or patient complaint for which the patient is seen. This diagnosis is listed in the first diagnosis space on the claim form and may change from encounter to encounter.

The company or plan who has first responsibility to pay benefits when there is duplicate coverage.

See "Predetermination" and "Precertification."

See "Predetermination" and "Precertification."

A patient contract provision whereby BCBSKS assumes only its proportionate share of liability when a patient has coverage through more than one insurance company. See "Subrogation."

The five-digit numeric identifier of the service performed. See "HCFA common procedure coding system."

The charge for a doctor examining, interpreting and expressing their opinion in a written report of an x-ray or lab test.

See "Physician Profiling System."

See "Enrollment area."

See "Subjective Objective Assessment and Plan Documentation" and "Medical Recordkeeping."

An individual, institution, facility, group or organization qualified to give healthcare services to our members/members -patients.

See "Contracting provider agreement."

The BCBSKS field representative who provides a liaison between the healthcare facility community and BCBSKS. The representatives work in the Provider Relations Department. The providers bill on the UB 92 claim form.

See "Contracting provider agreement."

The amount contracting deliverers of healthcare services agree to write off when signing contracts with certain networks.

See "Individual provider number" and "Group provider number."

See "Physician Profiling System."

The yearly and/or lifetime total dollar amounts that the patient contract mandates. Substance abuse services are applied to these limits.

See "RPT."