Glossary of Health Insurance Terms

As you explore our site, you may come across an unfamiliar word or term. We've developed a glossary that we hope will help you.

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Blue Cross of Kansas

The part of BCBSKS that is responsible for facility -i.e. hospital, hospice, home health agencies, etc. coverage and benefits.

Blue Plan

A BCBS entity usually referring to BCBSKS, but can be any other BCBS Plan. BCBSKS is not actually a Plan but is legally a mutual company.

Blue Select

A type of health insurance coverage that BCBSKS sells. This is a form of managed care and has two levels of benefits: PCP referred services and patient self-referred services. This coverage is considered a POS type of contract.

Blue Shield of Kansas

The part of BCBSKS that is responsible for professional -i.e. doctor, ambulance, dental, etc. coverage and benefits.

BlueCard Program

A teleprocessing system, in which BCBSKS participates, that serves Blue Cross and Blue Shield -BCBS members anywhere in the United States. This process is sometimes referred to as "ITS". Through this system, BCBS Plans make available to BCBS members the same provider discounts they have negotiated for their own customers. Claims for patients who have out-of -state coverage by another Blue Plan, are usually sent directly to BCBSKS. This program does not include HMO claims.

Boeing Vision Network (BVN)

A group of providers who have agreed to provide vision services -eye exams and/or corrective lenses to Boeing participants at a discounted amount.

BSA

See "Blue Cross Blue Shield Association."

Bundling

The act of combining procedures where one procedure is considered part of another procedure. The reimbursement could be based on a global fee for all services, or it could be based on the procedure with the highest RVU. See "Content of Service" and "Unbundling."

BVE

Boeing Vision Exam. See "Boeing Vision Network."

BVH

Boeing Vision Hardware -i.e. glasses, contact lenses. See "Boeing Vision Network."

BVN

See "Boeing Vision Network."

Calendar year

The period between Jan. 1 and Dec. 31 of any given year.

CAP

See "Competitive Allowance Program."

CAP Provider

A healthcare provider who has entered into a contract with BCBSKS. This provider has agreed to submit all claims and to accept our maximum allowable payment -MAP amount as payment in full, looking to the patient for only deductible, coinsurance, copayments, member contract indemnified payment limitation balances and non-covered service amounts. BCBSKS, in turn, will pay the provider directly and in a timely manner.

Capitation

A per member, monthly payment to a PCP, that covers contracted services. A PCP agrees specified services to pay members for this fixed, predetermined payment for a specified length of time, regardless of how many times the member uses the services.

Carrier

Any entity that underwrites or administers health insurance. This may be a government agency, a Blue Plan, a mutual company, a commercial insurer, or a company that contracts with a governmental agency. See "Medicare Part B Carrier."

Carry-over

Some major medical patient contracts allow charges incurred during the last three months of the patient's benefit period -calendar or contract/anniversary year to be applied to the deductible for the next benefit period.

Carve out

The method used to determine the benefits that are paid under a patient's contract when Medicare Part A, Medicare Part B or a liability insurer are primary and the patient has benefits that correspond to the basic benefits for all members of the patient's group. BCBSKS will compare Medicare's coverage and reimbursement to their coverage and reimbursement and will make additional payments as appropriate.

or

To separately purchase services that are typically part of a managed care package. For example the HMO may "carve out" the vision care benefit and select a specialized vendor to supply these services on a stand-alone basis.

Case management

A voluntary program for the direction of the care for chronic diseases, severe injuries and catastrophic illnesses by a team of professionals who can advise the patient and physician about cost effective treatments and efficient uses of benefits. It is a program that assists the patient and family with complex healthcare decisions, with no additional cost to the patient for the service.

CAT/CT Scan

Computed axial tomography.

CCN

See "Claim Control Number."

Centers for Medicare & Medicaid Services (CMS)

The division of Health and Human Services in the Federal Government that oversees the Medicare and Medicaid programs. CMS was formerly known as the Health Care Financing Administration (HCFA).

Certificate of Medical Necessity (CMN)

The form used by an attending physician to attest to the medical need of home medical equipment -HME or service.

Charge comparison report

A yearly report available to contracting providers that compares the actual charge to be made on certain services to the maximum allowable payment -MAP and what the provider write-off -if any will be.

Charges

The amount of money that a provider bills for a given service(s).

Choice Care

A rider to the patient's basic health insurance contract. A benefit option offered by BCBSKS to members, where the patient is required to obtain hospital services from a designated Choice Care hospital in order to obtain full benefits under the terms of their contract.

Claim Control Number (CCN)

The unique numeric sequence that identifies a specific billing to BCBSKS for medical services rendered.

ClaimCheck

The auditing software system used by BCBSKS to ensure consistent adjudication of services. This system is sometimes referred to as GMIS.

Claims review

The method by which patients' services are examined prior to payment. The purpose of this is to validate the medical appropriateness of the service and to be sure that the cost of the service is not excessive.

Clean claim

A claim not requiring additional information and/or handling to process immediately through the claims computer system.

Clearinghouse

A system that allows electronic claims -paperless submission through a single source for most payors. The system transfers the claims to the appropriate payor electronically.

Clinical outcome

The state of a patient's health after receiving medical care.

CMN

See "Certificate of Medical Necessity."

CMS

See "Centers for Medicare & Medicaid Services."

CMS assigned procedure codes

This is the second level of codes in Centers for Medicare and Medicaid Services Common Procedure Coding System. These codes and their nomenclature are assigned by Health Care Financing Administration.

COB

Stands for "Coordination of Benefits" and is now called Other Party Liability or OPL. See "Other Party Liability"

COBRA

See "Consolidated Omnibus Budget Reconciliation Act of 1985."

Cognitive therapy

A service provided to retain or enhance information processing due to brain damage or brain dysfunction which alters the way in which a person perceives or responds. These services include, but are not limited to, treatment of memory loss, problem solving difficulties, short attention span and an inability to scan visually. These services are usually non-covered.

Coinsurance

The fixed percentage of the allowed charge that the patient's contract denotes as the patient's responsibility. These amounts are collectible at the time of service by contracting providers. Coinsurance amounts are generally 10, 20, or 50 percent.

Coinsurance maximum

The specified dollar amount of patient out-of-pocket expense for coinsurance that has to be met before BCBSKS will begin to pay 100 percent of the allowed charge for covered services.

Common pay provider number

A unique numeric identifier that allows several individual provider numbers to generate one common remittance advice and check from BCBSKS using one common federal identification number for the group. See "Individual provider number" and "Claims filing."

Competitive Allowance Program (CAP)

The methodology of reimbursement of, and contracting with, healthcare providers that BCBSKS implemented January 1, 1984. This network of providers is used for our traditional member -patient benefit programs.

Complementary coverage

A patient contract that pays the deductible and coinsurance of Medicare covered services. Some contracts pay less, and others may pay more than just these amounts.

Compliance

Refers to capability of voluntarily following the written instructions for using a drug or other prescribed treatment regimen. This can also refer to the provider's willingness to follow BCBSKS contract and policy memos.

Comprehensive major medical

The patient has a set amount of out-of-pocket expense -deductible, coinsurance and/or copayment before BCBSKS begins to reimburse for covered services at 100 percent of the MAP under the patient's benefit plan.

Computerized patient medical record

An electronic system that enables providers to capture, store and communicate healthcare information.

Confidential information

Non-public information that includes strategic and/or competitively sensitive information including, but not limited to, BCBSKS, the Blue Cross Blue Shield Association, or other BCBS company trade secrets, policies, procedures, data and processes.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

All groups having 20 or more employees are required by federal law -under the provisions of COBRA to provide expanded conversion privileges to covered employees and their dependents who are no longer eligible for group coverage for a specified amount of time. Unlike other laws, these provisions apply to groups with self-insurance programs.

Consultant

A practicing provider of a given specialty that BCBSKS contracts with to review claims of the same specialty.

Content of service

All of the expenses -procedures, tests, overhead, materials, etc. that are included in the allowance for any given service. See "Bundling" and "Unbundling."