Glossary of Health Insurance Terms

The unique sequence of numeric characters that BCBSKS assigns to each claim as it is imaged and before it is processed.

An alpha-numeric coding system that identifies the complaints, symptoms and diagnosis of a patient.

See "Experimental or Investigational."

The procedure codes that identify specific ingredients and dosage in a given injection.

See "Joint Commission on Accreditation of Healthcare Organizations."

The entity that oversees certain providers of health care services making sure they meet specific criteria. This helps ensure the patient receives quality health care.

Kansas Alcohol and Drug Abuse Counselors Association.

A group of CAP chiropractors and chiropractors practicing in Johnson and Wyandotte counties who have signed an additional contract with BCBSKS to provide services -at a possible discount for patients who have the KCN rider. These discounts are based on the AACPPY for each chiropractor. The discounts range from 0 percent to 50 percent off MAP. Effective January 1, 2001 in Johnson and Wyandotte counties KCN will use BCBSKC Preferred Care and Preferred Care Blue network providers for those patients having the KCN rider.

The provision in the patient's contract that directs them to a KCN chiropractor to receive full benefits. If the patient chooses a chiropractor that is not part of the network, they will have greater out-of-pocket expense. This rider applies to some BCBSKS ASO patient contracts. It does not apply to those groups that BCBSKS underwrites.

Refers to the 103 Kansas counties -excluding Johnson and Wyandotte over which BCBSKS has jurisdiction relative to patient and provider contracts. BCBSKS is a mutual company and actually is not a Plan, but for ease of understanding and reading we refer to BCBSKS as a Plan. This may also be referred to as Kansas plan area.

A discharge abstract service organization of BCBSKS which collects data from hospitals in the state of Kansas. KHDS was developed for the use of hospitals and their medical staffs to efficiently collect and process data to facilitate daily hospital tasks.

BCBSKS is a mutual company and actually is not a Plan, but for ease of understanding and reading we refer to BCBSKS as a Plan.

Kansas Chiropractic Association.

See "Kansas Chiropractic Network."

Kansas Emergency Medical Technicians Association.

See "Kansas Health Data System."

Kansas Optometric Association.

Kansas Physical Therapy Association.

See "Comprehensive major medical."

The greatest total amount that a patient's contract will pay out, in the patient's lifetime.

Contractual restrictions placed on services or benefits as specified in a patient's contract.

Refers to the categories of activities at BCBSKS relative to type of claim and where the money comes from to pay the claim. Examples would be Blue Cross, Medicare Part B, Blue Shield, Medicare Part A and Medicaid. Originally this was an accounting term used to identify the line or the budget being affected. Today it has carried over to help identify where the benefits fit in the patient's contract. Can also refer to the type of services paid by BCBSKS as in professional, drug, in-hospital, outpatient hospital, and dental.

See "Line of Business."

This is the third level of the Health Care Financing Administration Common Procedure Coding System. These codes and their nomenclature are unique to the Medicare Carrier or the insurance carrier and are assigned by them.

A patient agreement -contract, underwritten and administered by BCBSKS.

The maximum amount for which a patient is responsible for covered services during their contract year.

Licensed Practical Nurse.

Licensed Speech Pathologist.

A patient contract addendum that provides benefits in addition to those in the basic contract.

Midwest Association of Medical Equipment Suppliers.

A patient contract that employs the primary care physician -PCP concept. The PCP has the responsibility of directing the patient's course of treatment, which includes the possible referrals to other health care specialists. The primary goal is to deliver cost-effective healthcare without sacrificing quality or access. Blue Select is a BCBSKS managed care product.

Coverage for healthcare services that insurers are required by state or federal law to provide for patients.

The skillful treatment of subluxations through certain chiropractic and osteopathic methods.

See "Maximum Allowable Payment."

The department at BCBSKS that sells health insurance and is responsible for the relationship between employer groups and non-groups members/members. BCBSKS also has a subsidiary company called Advance Insurance Company that sells life, accident, death and dismemberment and disability products.

The BCBSKS employee who sells to and provides a liaison for the employer groups and non-group members/members and BCBSKS.

Means the amounts established by BCBSKS as the highest amount reimbursed for services which are covered under the terms of the patient's contract. Our Board of Directors reviews these allowances each year for increases for the next calendar year. We may make adjustments to individual MAPs throughout the year if it is determined to be insufficient for a given service. Providers no longer establish customaries and prevailings, nor register charges with us as before BCBSKS implemented CAP -with MAP reimbursement on Jan. 1, 1984.

Medical Doctor.

Title XIX of the Social Security Act Amendment of 1965 which provides state and federally funded coverage for those who meet certain requirements based on their financial status. Sometimes referred to as welfare or Title XIX.

The entity that contracts with the state government to process Medicaid claims.

The position at BCBSKS that oversees the day-to-day activities of medical and utilization review for BCBSKS claims.

See "Emergency medical care."

The patient's contract describes medically necessary services as those that:

• Are performed or prescribed by a doctor.
• Are consistent with the diagnosis and treatment of a patient's condition.
• Are in accordance with standards of good medical practice.
• Are not for the convenience of the patient, his/her family or the provider.
• Are provided in the most appropriate setting.

The office documents that support:

• Charging practices.
• Accounts receivable.
• Type of service performed.
• That the service was actually performed.
• Medical necessity of the service.

These records would include but not be limited to:

• Appointment books.
• Ledgers.
• Invoices.
• Exam findings.
• Daily progress notes.
• Histories and physicals.
• Lab and x-ray reports.
• Consultation reports.

A contracting provider agrees to make this information available to BCBSKS at no charge. Accepted methods of documentation for daily medical records include Subjective, Objective, Assessment and Plan – SOAP Notes and History, Exam, Assessment and Layout – HEAL.

The department at BCBSKS that oversees the application of medical necessity policies and utilization guidelines for BCBSKS.

Coverage chosen by some groups for employees age 65 or older or disabled to provide benefits which, combined with Medicare benefits, will bring the over-all level of benefits up to the same level of benefits provided for those in their group under 65 or not disabled.

Title XVIII of the Social Security Act Amendment of 1965 which provides federal coverage for hospital inpatient, skilled nursing facility and home health care agency services for persons age 65 or older or those disabled.

The entity that contracts with the federal government to process the Medicare Part A claims.

Title XVIII of the Social Security Act Amendment of 1965 which provides federally funded coverage for outpatient hospital, home, and office care for persons age 65 or older or those disabled.

The entity that contracts with the federal government to process Medicare Part B claims.