Glossary of Health Insurance Terms

Usually refers to the company or the procedure of being financially responsible for the costs of the care contracted for. The company receives premiums from the employer or from the member/member -patient which may or may not be enough to cover the actual expense of the care received. The underwriter -company takes full financial responsibility for the payment of those covered services regardless of the total amount of monies received in premiums.

Usually refers to the UB-92 or the HCFA-1500 -12-90 documents that are used by providers to request reimbursement for medical services.

Health Care Financing Administration assigned specific group of numeric characters for every doctor in the United States.

The three digit numeric representation of time/regions/number of services performed on a given date.

The procedure codes that are not specific to any service. When using these, you must identify what service or item you have provided.

See "Unlisted Procedure."

The intentional or accidental act of changing a procedure code, such as a CPT code digit, to reflect a higher intensity of care than was actually performed and thus receiving a higher level of reimbursement.

See "Unique Physician Identifying Number."

See "Utilization Review."

See "Utilization Review Accreditation Commission."

The fee most commonly charged for a given service by the provider to the general public. This charge cannot be higher to BCBSKS if the provider is contracting.

The formally established process for determining the appropriateness of services rendered to our members/members -patients and of payments, through an analysis of medical necessity. Proper documentation ensures that the services in question are reimbursed appropriately. See "Medical Recordkeeping" and "Subjective, Objective, Assessment and Plan Documentation."

A Washington based, nonprofit corporation, dedicated to improving the quality of utilization review by providing a method of evaluation and accreditation of utilization review programs and PPOs.

 Veteran's Administration.

The period of time between the effective date of the patient's contract and the date when benefits are available. It may be 240 days or 270 days and may apply to only certain specified conditions. There are usually two kinds of waiting periods; insurance company -imposed -i.e. maternity benefits may not be available for 240 days after the effective date of the patient's contract and pre-existing condition -i.e. care for back conditions may not be available for 240 days from the effective date of the patient's contract when there is evidence of previous care for this condition.

A form that a provider must have the patient sign that notifies the patient of financial responsibility if the services are questionable as to medical necessity or are considered deluxe or custom items.

See "Workers' Compensation."

See "Medicaid."

The BCBSKS Wichita site that houses the provider relations, professional relations, Medicaid, Medicare and marketing representatives and medical review staff.

The portion of the monthly capitation payment to PCPs that is not paid to them until the end of the designated time period. The PCP may be paid all or a portion of this money if they meet certain performance standards during the designated time frame.

See "Workers' Compensation."

See "Workers' Compensation."

The total patient evaluation, which may include but not be limited to assessments, radiologic series, medical history, and diagnostic procedures.

The insurance coverage for injuries or illnesses that arise out of or in the course of employment without regard to negligence or fault. The employer purchases this coverage. Services should be billed to the WC insurance carrier first and then billed to BCBSKS attaching the WC carrier's payment decision. The Kansas provision states that the patient may seek care from the provider of their choice for the first $500 of incurred charges.

The written results of the study of a given x-ray. These documents should be kept with the patient's file and made available to BCBSKS upon request without charge.

Usually used in reference to accumulated services or monies paid.

See "Year To Date."