Glossary of Health Insurance Terms

See "Final level appeal."

The insurer who processes the services after the primary insurance carrier has made their adjudication of the services.

See "Internal Control Number."

Treatment, care or item provided to a patient. See "HCFA Common Procedure Coding System" and "Procedure Code."

The area in which the provider practices or has their business.

Under this program the patient pays 50 percent of the allowed charge on covered services up to a designated amount. BCBSKS pays the other 50 percent. The patient's premiums are usually less costly with this plan.

The expense incurred under a patient's contract that is transferred to another contract. For this to happen, the expenses and contract effective dates must be in the same contract year.

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

Only the member/member -patient is covered as opposed to family coverage where the member/member, the spouse, and dependent children are covered.

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

The State of Kansas department that oversees Outpatient Substance Abuse Facility licensing. This is also the department that regulates the state Medicaid program.

See "LSP."

A healthcare plan offering a program that encompasses benefits and/ or medical services outside of normal benefits.

See "Self Referral Option."

See "Social and Rehabilitation Services."

Social Security Administration.

The average charge made by BCBSKS contracting providers for a given service.

The group of BCBSKS employees that are responsible for overseeing the running of the company. This committee is comprised of the President and Vice-Presidents.

See "Individual stop loss."

See "Individual stop loss."

An accepted method of recordkeeping to support the medical necessity and actual services rendered to our members/members -patients. See "Medical Recordkeeping."

BCBSKS' right to recoup monies paid when another insurer has legal responsibility for payment of expenses. The substitution of one for another as creditor so that the new creditor succeeds to the former's rights or obligations.

The department at BCBSKS that has responsibility of billing and setting up the eligibility of our BCBSKS members -patients.

See "Medicare Part B."

A request for payment that has been delayed for payment until further development can occur.

See "Suspended claim."