Glossary of Health Insurance Terms

See "Date of Birth."

See "Medical Recordkeeping."

Date of Death

See "Date of Service."

See "Diagnosis Related Groups."

This provision applies to covered group employees (or family members of the employee) who are eligible for benefits from another group healthcare plan. Duplication of benefits coordination is conducted to make sure members do not profit by receiving payment from more than one source.

See "Home Medical Equipment."

CMS Central Office, in Baltimore, has elected to contract with a limited number of entities to process home medical equipment for the Medicare Part B program. Vision correction hardware and home medical equipment provided in Kansas for Medicare Part B beneficiaries should be submitted to CIGNA -Connecticut General Life Insurance Company. If the provider has questions about this procedure, they should contact their Kansas Medicare Carrier or CIGNA directly.

See "Diagnosis."

See "Evaluation and Management Procedure Codes."

See "Electronic Data Interchange."

The day that a patient or provider contract begins. Rules, regulations and guidelines for claims processing can also have effective dates.

See "Employer Identification Number."

The exchange of health care information, in the case of BCBKS this is claims information, between two entities, via computer technology.

The paperless submission of claims via computer tape or telephone wires. For more information call BCBSKS Electronic Media Services at 1-800-472-6481 or 785-291-7153.

See "Emergency Medical Care."

A sudden unexpected onset of a health condition that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect requirement of immediate medical attention, where failure to provide would result in serious impairment to functions of a body organ or part, or would place the patient's health in serious jeopardy.

Ambulance companies. Can also refer to care given to a patient in an extremely urgent situation.

Federal legislation that establishes certain rights and protections to participants of most employer welfare (e.g., health, dental, life) and pension (e.g., 401(k), retirement) benefit plans.

Federal Tax Number that is used to generate Federal 1099 forms to IRS.

See "Electronic Media Services" or "Emergency Medical Services."

The geographic location of a managed care program -i.e. Blue Select, to which a member/member -patient belongs.

See "Explanation of Benefits."

See "Explanation of Medicare Benefits."

A specified time frame that includes all care administered for a given disease.

See "Exclusive Provider Organization."

See "Employee Retirement Income Security Act of 1974."

The codes for office calls, consultants, nursing home visits and inpatient hospital calls in the AMA CPT book. These codes are based on the complexity of 1 the patient's condition, and 2 the provider's decision-making process. These are referred to as E and M codes.

See "Contract Exclusion."

This is a form of a PPO which requires the patient to seek care from a panel provider.

A service, piece of equipment, facility or supply -including drugs or drug usage that has not been proven effective to the point that it has been accepted as standard medical practice by the general medical community, and/or does not have federal approval. BCBSKS considers these provider write-offs unless a waiver is signed prior to the service being rendered.

The computer-generated explanation of benefits that is mailed to a patient when BCBSKS processes claims. If the provider is contracting they receive a RA giving the same information. This explanation indicates how much was paid, what the patient's responsibility is and what the provider write-off amount is.

The summary sheet that outlines how Medicare processed services submitted to them on behalf of their beneficiaries.

A computer generated document for a BCBSKS Plan 65 or MER claim, where Medicare was primary.

The member/member, spouse and their dependent children are included in the benefit. Separate types of patient contracts may have different rules and regulations regarding the age and status when dependent children are no longer covered.

Food and Drug Administration of the Federal government.

A benefit program for United States government employees, their families and retirees. BCBSKS administers this program for the employees in the state of Kansas excluding Johnson and Wyandotte counties. This program has different coverage than the regular FEP Program. You should call FEP Customer Service for the specific information.

A benefit program for United States government employees, their families and retirees. BCBSKS administers this program for the employees in the state of Kansas excluding Johnson and Wyandotte counties. This program has different coverage than the FEP POS program. You should call FEP Customer Service for the specific information.

See "Employer Identification Number."

A method of payment to providers where there is a set amount for each procedure billed.

A listing of allowed charges for given procedures.

See "Federal Employee Program."

See "Federal Employee Point of Service Program."

See "Fee for Service."

The last step in the BCBSKS appeal procedure. A committee designated by the board of directors makes the decision in this step.

A patient insurance contract where there is no deductible and at the effective date of the contract all covered services are paid at 100 percent of the allowed charge or a percentage of the allowed charge. An example would be when all covered services are paid at 80/20 percent; with the insurer paying the 80 percent and the patient being responsible for 20 percent.

See "Initial appeal."

When a claim enters into our computer system and processes the initial time through.

See "Medicaid fiscal agent."

Includes, but is not limited to, any of the following: (1) breach of contract; (2) a civil case ruling, settlement in a civil or criminal matter, a verdict or plea of guilty or a plea of nolo contendere, and/or any other instance determined by BCBSKS as moral turpitude; and/or (3) any act of defamation, slander, and libel toward BCBSKS and its subsidiaries (as determined by BCBSKS).