Glossary of Health Insurance Terms

A patient contract that provides benefits complementary to Medicare. Usually these contracts pay the deductibles and coinsurance amounts on Medicare-covered services only. Some supplemental contracts pay less than this and some may pay more.

A program that offers Medicare beneficiaries a wider variety of health plan options than previously, including preferred provider organizations and provider sponsored organizations. BCBSKS does not participate in this program.

Insurance that supplements the money paid by Medicare. This insurance usually pays the difference between what the provider charges and what Medicare allows for a given service. Plan 65 F contract is a form of this type of insurance.

Anyone who lives in the same dwelling who was claimed as a tax deduction during the year for which benefits were contracted.

Any person entitled to receive medical, surgical and ancillary services pursuant to the terms of HMO or managed care patient contract.

See "Medicare Exclusion Rider."

The two-digit alpha and/or numeric suffix that immediately follows the procedure code on the claim form. This suffix gives BCBSKS additional information about the service provided such as right eye, left eye, provider is requesting individual consideration, service performed was less than normal, etc.

See "Medical Review."

Magnetic resonance imaging.

Manipulation under anesthesia.

See "Units of Service."

The factor by which some procedure codes' MAPs may be determined when used in conjunction with the Kansas adjusted RVU for the procedure code.

National Association of Medical Equipment Suppliers.

A business who has employees in more than one Blue Cross and Blue Shield Plan area that provides consistent coverage for all of their employees. Special arrangements are made with these businesses to maintain equal benefits throughout each Blue Cross and Blue Shield Plan that would have the business' employees in the Plan's jurisdiction.

See "Blue Cross and Blue Shield Association."

A private, not-for-profit organization that assesses and reports on the quality of the nation's managed care. Their mission is to provide information that helps purchasers of managed health care to make informed health care purchasing decisions.

The numeric identifier of the medicine being administered. This identifier is listed on the packaging material of the medicine.

See "National Committee for Quality Assurance."

See "National Drug Code."

A defined group of providers, typically linked through contractual arrangements with the insurance company or payor.

A "closed" network is one in which patients are not allowed to access non-network providers without the service being considered non-covered.

An "open" network allows access to other providers at some cost to the patient, this is referred to at BCBSKS as SRO.

A Doctor of Chiropractic who has signed the BCBSKS "Kansas Chiropractic Network" -KCN provider agreement.

A provider of eye care services who has signed the Boeing Vision Network -BVN provider agreement(s).

An employee group that has contracted with us to use BCBSKS allowance for their claims utilizing our CAP Network and MAPs.

Any person or entity that has signed a contract with BCBSKS to participate in a specific program.

Coverage that pays for losses associated with a motor vehicle accident regardless of the fault of the driver.

See "Non-contracting provider."

A provider of healthcare services to which BCBSKS has offered a contract and the provider has elected not to sign the contract. Reimbursement for services rendered by a non-contracting provider is made to the patient even when the provider has submitted the claim. The patient may not assign the payment to the non-contracting provider.

The patient is responsible for amounts in excess of the MAP. The provider may collect for all services at the time of service. This does not apply to those providers that we do not contract with their provider type, i.e. registered nurses, licensed practical nurses, opticians or hearing aid dispensers

Medical care for which benefits are not provided under the patient's contract. Non-covered services are the patient's financial responsibility. The contracting provider may collect for these services at the time they are rendered. These should not be confused with services that are determined to be not medically necessary, experimental or investigational. The contracting provider may not collect for these unless the patient has signed a waiver prior to the service being rendered.

See "Non-contracting provider."

See "Non-contracting provider."

A giver of health care services who is eligible for reimbursement from BCBSKS but BCBSKS does not contract with them.

See "Unlisted procedure."

See "Unlisted Procedure."

Right eye.

Doctor of Optometric Medicine

Overdose.

The setting in which services are provided to a patient who is not seen in an inpatient or an outpatient hospital setting -i.e. provider's clinic, place of business.

The procedure whereby BCBSKS recoups overpayments to contracting providers by deducting monies from current payments before they are mailed.

The computerized logging of incoming and outgoing calls to and from BCBSKS Customer Service Center. The correspondents type the information from the calls into the computer. They log the date of the call, the patient, the person-s talked to, the nature of the concern and any follow-up action planned to resolve the problem.

The day the illness or symptoms began. For specialty providers, we are only interested in the accident date.

Opticians of America.

Optician.

A health plan that lets a member visit any doctor in the plan's network. A referral isn't needed from a primary care physician.

A period during which individuals not previously enrolled in the health insurance plan are allowed to apply for coverage or change their coverage status.

Left eye.

See "Outpatient Substance Abuse Facility."

Occupational Safety and Health Administration of the Federal government.

Occupational Therapist.

The anti-duplication provision of the patient's contract that limits benefits being paid by multiple insurers to 100 percent of the expenses covered and to designate the order in which the liability lies. -This was previously referred to as COB or Coordination of Benefits.

See "Online Tracking Inquiry System."