Glossary of Health Insurance Terms

See "Primary Care Physician."

GMIS - See "ClaimCheck."

The time between which a rule or regulation is put in place and the time that it is enforced.

A membership of members/members -patients enrolled in BCBSKS through a specific business organization, association, legal entity, or employer. BCBSKS sells two types of health insurance coverage related to this, group and non-group. See "Non-Group."

When a member -patient elects to move from a specific group to non-group status and is paying premiums directly to BCBSKS.

See "Common pay provider number" and "Individual provider number."

See "Physician Profiling System."

A system of reporting medical services performed that is used nationally. The system consists of three levels of codes: Level 1 is the AMA's CPT codes; Level 2 is HCFA assigned codes and nomenclature; and Level 3 is the local codes and nomenclature assigned by each Medicare Carrier or the insurance carrier and is unique to them. This system is updated annually.

The national uniform claim form used to identify and request reimbursement for medical services provided to patients.

See "HCFA Common Procedure Coding System."

See "History, Exam, Assessment and Layout."

A comprehensive package of benefits identified for specified chronic diseases and intended to improve long-term patient outcomes.

This is the Kennedy-Kassebaum Act that intends to provide patients the ability to take insurance coverage with them between employment. This law also prevents insurance companies from excluding patients with pre-existing conditions. There are other provisions of the law. The ones cited here are two that affect providers and BCBSKS.

An entity that makes available medical care services for members -patients at a predetermined, usually global periodic reimbursement rate, to the PCP. HMOs require a PCP to direct the care of the member.

The subcontractor that BCBSKS uses to pre-certify psychiatric care.

A report card developed by NCQA for employers and consumers to use to compare managed care plans to one another.

A form when completed by the applicant that offers health history information and is used to determine the premium and establish coverage.

See "Health Plan Employer Data and Information Set."

See "Health Insurance Portability and Accountability Act of 1996."

An accepted approach to patient processing and recordkeeping in a physician's office. See "Medical Recordkeeping."

Home infusion therapy.

See "Home Medical Equipment."

See "Health Maintenance Organization."

See "Health Management Strategies."

A piece of equipment that replaces a malfunctioning body part. It must be able to withstand repeated use and not be useful if the body part were functioning properly. The item must be prescribed for, in most cases, by the patient's attending physician. Also referred to as Durable Medical Equipment (DME).

A Blue Cross and Blue Shield Plan that is part of the BlueCard Program which administers the benefits for services incurred by their member in another Blue Cross and Blue Shield Plan's area.

A practitioner who follows the philosophy that “like cures like.” These practitioners usually try to match a person’s personality, habits, and symptoms with a remedy. The remedy is usually a highly diluted substance that is believed to create the same symptoms that an illness has created in the consumer. These services are non-covered under BCBSKS.

A Blue Cross and Blue Shield Plan that is part of the BlueCard program which makes payments for services rendered by a provider in their Plan area for a patient from another Plan.

See "International Classification of Diseases."

See "Individual Consideration."

See "International Classification of Diseases."

See "Internal Control Number" and "Inquiry Control Number."

The card issued to identify a member of BCBSKS and what coverage the member and any family members on the policy have.

A series of numbers and alpha characters which are unique to each member/member -patient contract. This series of numbers and alpha characters identify the member, their spouse and dependent children in our computer system.

A charge billable on the date that the service is performed or the supply or equipment is delivered.

See "Indemnity contract."

See "Contract indemnified payment limitation balance."

See "Indemnity contract."

A patient contract that pays a set amount for a specific service, balances are patient's financial responsibility.

By using modifier "22" immediately following the procedure code, a provider may request special review of the service because of unusual circumstances. Additional information must accompany the claim. This information should document the unusual circumstances.

A unique numeric identifier for each eligible provider that gives BCBSKS an audit trail of who performed the services and who was reimbursed for those services. See "Common pay provider number" and "Claims filing". Without this information BCBSKS is not able to determine whom to pay.

When a patient's contract requires that a coinsurance amount be the patient's responsibility, there is also a total amount that the patient has as out-of-pocket expense for covered services before BCBSKS begins to reimburse 100 percent of the allowed charge; this amount is referred to as the individual stop loss.

The first step or first level in the BCBSKS appeal procedure. A peer consultant makes the decision at this level.

When a patient is hurt during work-related duties, it is referred to as injured on the job, work comp, work compensation, or work related injury. These services are always filed with the Workers' Compensation carrier first.

See "Accidental injury."

A patient who is staying in the hospital and receiving room, board and general nursing care.

The unique numeric sequence that identifies a specific contact to CSC.

Any person entitled to receive medical, surgical and ancillary services pursuant to the terms of BCBSKS underwritten or administered contracts referencing contracting providers.

See “BlueCard Program.”

See "Medicare Part A Intermediary."