Glossary of Health Insurance Terms

As you explore our site, you may come across an unfamiliar word or term. We've developed a glossary that we hope will help you.

A (37) B (24) C (69) D (30) E (25) F (16) G (6) H (22) I (24) J (3) K (12) L (10) M (34) N (21) O (23) P (69) Q (5) R (22) S (26) T (17) U (18) V (1) W (10) X (1) Y (2)
OU

Both eyes.

Out of Kansas Plan area

Any location other than the 103 counties in Kansas over which BCBSKS has jurisdiction. See "Anthem Blue Cross and Blue Shield, Inc." and "Kansas Plan Area". 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.

Out of pocket expense

The money the patient pays for their medical care. Usually defined in their contract to be a certain amount in relationship to the coinsurance and/or deductible. See "Individual stop loss."

Outlier

Someone or something that does not fall within the norm; typically used in utilization in as a provider who uses either too many services or too few services, or both. For example: anyone whose utilization differs two standard deviations from the mean on a bell curve could be termed an outlier from their peers.

Outpatient

The setting in which services are provided to a patient who is seen in a non-inpatient setting -i.e. outpatient department of hospital, ambulatory surgery center, can also refer to the office setting.

Outpatient Substance Abuse Facility (OSAF)

An entity licensed through State of Kansas Department of Social and Rehabilitation Services -SRS to provide substance abuse care.

PA

Physician Assistant.

PA

Professional Association.

PAR

Participating or contracting provider.

Part A

See "Medicare Part A."

Part B

See "Medicare Part B."

Participating plan

A Blue Cross and Blue Shield Plan that has agreed to provide coverage for a National Account.

Patient

See "Insured" and "Member."

PC

See "Professional Component."

PCP

See "Primary Care Physician."

PDR

See "Physician's Desk Reference."

Pended claim

A bill for service(s) that has been put on hold until additional information is obtained.

Performing provider number

See "Individual provider number."

Personal Injury Protection (PIP)

Used for determination of benefits payable under the other party liability provision of the patient's contract when there has been a motor vehicle involvement.

PET

Positron emission tomography.

Physical medicine rider

The provision in the patient's contract that provides limited benefits for physical therapy, physical medicine modalities, occupational therapy, speech therapy, respiratory therapy, approved cardiac rehabilitation, pulmonary rehabilitation, and perceptual therapy. Physical medicine services by a chiropractor, occupational therapist, speech pathologist or physical therapist, such as cold packs, ultrasound, tests and measurements, treatments for speech disorder, etc. are usually applied to this benefit limit annually.

Physician's Desk Reference (PDR)

A book listing drugs, their appropriate use and possible side effects.

PIP

See "Personal Injury Protection."

Place of service

The location where the service was performed.

Plan

See "Blue Plan."

Plan 65 Benefit A

BCBSKS insurance coverage that pays after Medicare Part B. It does not cover the Medicare Part A or Part B deductibles. It covers only the Medicare Part B 20 percent coinsurance. This coverage also includes the coinsurance for the 61st through the 90th day of inpatient care.

Plan 65 Benefit C

BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance and limited coverage for services received in a foreign country.

Plan 65 Benefit F

BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance, limited coverage for services received in a foreign country and the amount in excess of the Medicare allowed charge on non-assigned claims.

Plan 65 over age 65

BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles and the Medicare Part B 20 percent coinsurance.

Plan 65 Select Benefit C

BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance and limited coverage for services received in a foreign country. For hospital benefits to be paid the patient must seek care at a Plan 65 Select hospital.

Plan 65 Select Benefit F

BCBSKS insurance coverage that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles, the Medicare Part B 20 percent coinsurance, limited coverage for services received in a foreign country and the amount in excess of the Medicare allowed charge on non-assigned claims. For hospital benefits to be paid the patient must seek care at a Plan 65 Select hospital.

Plan 65 under age 65

BCBSKS insurance coverage, for those disabled, that pays after Medicare Part A and Part B. It covers the Medicare Part A and Part B deductibles and the Medicare Part B 20 percent coinsurance.

Plan area

The geographic jurisdiction of a specific Blue Cross and Blue Shield. See "Kansas Plan area."

Plan of treatment

See "Treatment plan" and "Medical recordkeeping."

Point of Service (POS)

A prepaid health plan or insurance program, that offers the convenience and comprehensive coverage of a managed benefits program by working with a PCP for maximum benefits. It also allows the patient to self-refer at a lower payment level of benefits, as with the flexibility of a traditional benefits program. Sometimes referred to as Self-Referred Option -SRO. Blue Select is a POS type of contract.

POS

See "Point of Service" and "Place of Service."

Post-payment review

The procedure by which BCBSKS reviews and re-adjudicates -if appropriate claims that have already been processed.

PPO

See "Preferred Provider Organization."

PR

Professional Relations Department at BCBSKS. This department handles education of and problems for the providers who bill on the HCFA 1500 claim form.

PR

Provider Relations Department at BCBSKS. This department handles education of and problems for the providers who bill on the UB 92 claim form.

PR

Public Relations Department at BCBSKS. This department handles inquires from outside entities such as newspapers, television stations, radios etc.

PR Representative

The BCBSKS field representatives who provide a liaison between the health care provider community and BCBSKS. The representatives work in the Professional Relations and Provider Relations Departments. Those using this manual would work with the representatives in Professional Relations. The representatives in Provider Relations work with hospitals and are titled Provider Consultants.

Pre-Existing Condition

An injury or illness that is evident before the effective date of the contract. Many health plans do not cover pre-existing conditions. Or, they have a waiting period before the member can receive benefits for them. For example, you hurt your knee playing football a couple of years ago and had to have surgery. When you sign up for a new health plan, you'll have to list your knee injury as a pre-existing condition.

Pre-existing condition

Any illness, symptoms, or complications of any illness that existed prior to the effective date of the patient's contract. If the patient has received an evaluation, diagnosis, or treatment for the illness, symptoms, or complications of any illness within a specified number of days immediately prior to the patient's contract effective date; the illness, symptoms, or complications of any illness will be considered pre-existing. See "Pre-existing rider" and "Pre-existing waiting period."

Pre-existing rider

The provision in the patient's contract that excludes or limits coverage of a condition that was present prior to the effective date of the BCBSKS member contract. See "Pre-existing condition" and "Pre-existing waiting period."

Pre-existing waiting period

The time during which the patient contract prohibits coverage of a condition that was present prior to the effective date of that contract. This period of time is usually 240 or 270 continuous days before benefits are available for the condition. See "Pre-existing condition" and "Pre-existing rider.

Preauthorization

See "Predetermination."

Precertification

The formalized procedure by which some services -i.e. hospital admissions are approved prior to being performed.

Predetermination

The procedure by which some services -i.e. air ambulance, customized wheelchairs, etc. may be approved prior to being performed or ordered. This is a service offered by BCBSKS to providers so the patient is aware of their financial responsibility prior to services being rendered or ordered. A letter or fax to CSC with a completed predetermination form will initiate the process.

Preferred Provider Organization

A group of doctors and/or businesses involved in healthcare services that have come together under a plan with specific guidelines and reimbursement amounts. As an example: BCBSKS' CAP network is the PPO Blue Choice.