Glossary of Health Insurance Terms

See "Contracting Provider Agreement."

An item or services specifically defined as non-covered in the patient's BCBSKS contract. These are the patient's financial responsibility.

The amount over and above the set amount identified in the patient's BCBSKS contract for a given service or item. This balance is the patient's financial responsibility.

See "Benefit period" and "Contract/Anniversary Year."

The period of time that an agreement is in effect. For a provider, it is usually a calendar year. This period for patient contracts may be a calendar year or a year from the effective date of patient enrollment such as April 1, 1999 through March 31, 2000.

See "Contracting Provider."

A healthcare provider who has entered into an agreement with BCBSKS. The provider agrees to submit all claims and accept what BCBSKS allows, bill the patient for only the coinsurance, copayment, deductible, member/member -patient contract indemnified payment limitation balance and non-covered service amounts.

The contract entered into by the contracting provider and BCBSKS. See "Contracting provider."

A Blue Cross and Blue Shield Plan that has entered into an agreement to administer a National Account. The National Account is usually headquartered in the Control Plan area. All other Plans that are involved in processing claims for the National Account are referred to as National Account Participating Plans.

Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.

See "Other Party Liability."

A specific set amount patients are required by their contract to pay on a given service. These amounts are not percentages of an allowance -coinsurance, but are a flat fee per the service. An example would be a $15 copay on office calls.

Means procedures and related services performed to reshape structures of the body in order to alter the individual’s appearance. Cosmetic services or supplies are usually patient contract exclusions. Some member contracts may offer limited coverage for cosmetic or reconstructive services if related to an accident, congenital abnormalities or when performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. Contact BCBSKS for specific coverage information.

Strategies used to limit or control healthcare costs that do not sacrifice the quality of care.

Financing arrangement whereby the patient must pay some of the bill to receive care.

An individual who meets a health plan's eligibility requirements and for whom premium payments are paid for specified benefits of the contract between the insurance carrier and a contract holder.

A service or supply for which BCBSKS will make reimbursement as outlined in the patient's contract.

Cardiopulmonary resuscitation.

See "Current Procedural Terminology."

Continuous quality improvement.

The process by which BCBSKS's Blue Select program ensure that the PCPs, referral specialists and consultants meet our quality of care standards.

The procedures established for providers to have our credentialing decisions re-examined.

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

See "Customer Service Center."

A published listing of procedure codes and nomenclature developed by the American Medical Association for reporting medical services. This is the first level of the Health Care Financing Administration Common Procedure Coding System.

Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.

Medical items that are not bought over the counter -i.e. custom stockings, customer wheelchair seating systems. These items cannot be used by anyone but the patient for whom they are made.

See "Usual, customary and reasonable."

The department at BCBSKS that responds to telephone and written inquiries from providers and patients regarding claims processing and benefits.

The month, day, year that a patient was born. This must match our records for the claim to process.

The month, day, year that a service was performed or an item was delivered.

Doctor of Chiropractic Medicine

A specified amount of out-of-pocket expense, a patient must pay in a benefit period before BCBSKS will begin reimbursement. These services must be submitted to BCBSKS so we may keep track of the expenses met. Deductible amounts are collectible at the time of service by a contracting provider.

Items or services that are added beyond the standard model and are not considered to be medically necessary.

From time to time, a patient may demand that items or services be provided when there is a question of medical necessity or coverage. The provider should have a waiver form signed. The waiver is kept in the patient's file. The modifier "GA" should be used with the procedure code on the claim.

A line item or entire claim that has been determined to have no benefit coverage due to patient or provider contract limits, duplicate service(s) already processed or duplicate coverage by another insurance carrier.

A person, entitled to health insurance, other than the person who holds the healthcare insurance policy. This is usually the spouse or child of the contract holding person.

A person eligible for coverage under a benefits plan because of that person's relationship to the primary member. Spouses and children are often eligible for dependent coverage.

Disease process identified by evaluation of patient's signs, symptoms, complaints, and test results.

See "International classification of diseases"

A payment methodology in which hospital procedures are rated in terms of cost and intensity of services delivered. A standard rate per procedure is derived from this scale, which is paid by the insurer, regardless of the cost to the hospital to provide that service.

A non-group member -patient who pays their insurance premium directly to BCBSKS, rather than an employer paying the premium to BCBSKS.

Any medical condition that results in major functional limitations that interfere with a patient's ability to perform normal activities of daily activity.

BCBSKS insurance coverage that pays after Medicare Part B has paid. This does not cover the Medicare Part A and Part B deductibles. It covers only the Medicare Part B 20 percent coinsurance amounts.

BCBSKS insurance coverage that pays after Medicare Part A and Part B have paid. This covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance and services received in foreign countries.

Non-payment or partial payment of services rendered. This may be for various reasons. It may be the service is non-covered under the patient's insurance contract.

A formalized plan to care for a patient with a chronic illness. The plan's goal is to help prevent recurrence of symptoms, prevent future need for medical resources and to maintain the highest possible quality of life. This approach utilizes roles played by pharmacy, case managers, care givers and family to obtain the best possible outcomes while helping to maintain overall lower costs. See "Healthcare management benefits."

See "Health care management benefits."

See "Durable Medical Equipment Regional Carrier."

Doctor of Osteopathic Medicine