Glossary of Health Insurance Terms

Doctors, hospitals and other health care providers who contract to provide healthcare services to patients covered by a particular health insurance plan. As an example: BCBSKS' CAP network providers are the preferred providers the Blue Choice product.

The procedure by which BCBSKS adjudicates claims based on specific guidelines relative to a given provider, patient, or procedure before the claim reaches final disposition through regular processing. Usually these claims require medical records to be submitted with the claim.

The order written by the attending physician relative to services, equipment or drugs to be dispensed.

Medicines requiring the written dispensing and usage instructions of a medical doctor -MD or doctor of osteopathic medicine -DO, purchased through a pharmacy or the office of the MD/DO.

The doctor of medicine or osteopathy, selected by the patient, who provides or coordinates all the patient's healthcare needs. These providers are sometimes referred to as gatekeepers. The PCP is usually the first provider a patient sees for care. The PCP usually treats the patient directly, refers the patient to a referral specialist -secondary care giver or admits the patient to a hospital.

See "Primary insurance carrier."

The main condition, illness, injury, symptom or patient complaint for which the patient is seen. This diagnosis is listed in the first diagnosis space on the claim form and may change from encounter to encounter.

The company or plan who has first responsibility to pay benefits when there is duplicate coverage.

See "Predetermination" and "Precertification."

See "Predetermination" and "Precertification."

A patient contract provision whereby BCBSKS assumes only its proportionate share of liability when a patient has coverage through more than one insurance company. See "Subrogation."

The five-digit numeric identifier of the service performed. See "HCFA common procedure coding system."

The charge for a doctor examining, interpreting and expressing their opinion in a written report of an x-ray or lab test.

See "Physician Profiling System."

See "Enrollment area."

See "Subjective Objective Assessment and Plan Documentation" and "Medical Recordkeeping."

An individual, institution, facility, group or organization qualified to give healthcare services to our members/members -patients.

See "Contracting provider agreement."

The BCBSKS field representative who provides a liaison between the healthcare facility community and BCBSKS. The representatives work in the Provider Relations Department. The providers bill on the UB 92 claim form.

See "Contracting provider agreement."

The amount contracting deliverers of healthcare services agree to write off when signing contracts with certain networks.

See "Individual provider number" and "Group provider number."

See "Physician Profiling System."

The yearly and/or lifetime total dollar amounts that the patient contract mandates. Substance abuse services are applied to these limits.

See "RPT."

See "Quality Assurance."

See "Quality Improvement."

An event such as death, divorce or spouse's loss of employment that would allow enrollment in another health plan without having to wait for an open enrollment period.

The activity that monitors the level of care being provided by healthcare providers in order to ensure that patients receiving the best care possible.

The department at BCBSKS that oversees credentialing providers for managed care products. This department also is responsible for addressing BCBSKS and providers' compliance with federal guidelines in relationship to the care given members/members -patients.

See "Remittance Advice."

See "Resource Based Relative Value Study."

The interim procedure that is used to determine the continued validity of a managed care provider's credentials. This process takes place after credentialing and before re-credentialing; or between re-credentialing processes - which is every three years when there is just cause.

The process performed every three years after a provider has been credentialed by BCBSKS. This is sometimes referred to as “re-cred.” See “Credentialing.”

If a primary care physician (PCP) determines a patient has a condition which requires the attention of a specialist, the PCP coordinates the transfer of care to a specialist.

A Blue Select provider who has signed an agreement to extend services to patients. These providers are not PCP and the scope of their practice or business is limited to a type of service or specific body system(s).

The doctor who has the responsibility for the care of the patient and who has requested that another doctor or healthcare professional see the patient for a certain condition, system, diagnosis or complaint.

Requests for money that are made of a provider or patient when a claim has been processed in error. Another form of refund is when a patient has overpaid a contracting provider coinsurance and deductible amounts and the provider is required to pay the patient the overpayment.

A denied request for payment. These denials may be due to various reasons. Some of the more common ones are duplicate of an already processed claim/service, non-covered service-s or another insurance carrier is responsible for processing the claim/service first.

The numeric assignment to a procedure code that indicates the value of the service.

A computer generated report that explains the processing of a claim. There is usually more than one claim on a RA and can list many different patients. RAs are used by providers to post their accounts receivable.

BCBSKS PR field staff member who provides a liaison between the health care community and BCBSKS; or the Marketing staff member who sells BCBSKS health insurance and provides a liaison between employer groups and non-group patients and BCBSKS. This can also be the PR field staff member who provides a liaison between the hospitals and BCBSKS, these staff are also referred to as provider consultants.

A claim form, usually the HCFA-1500 -12-90 or the UB92.

A drug, device, medical treatment or procedure that may be covered -even though otherwise excluded by the patient's contract as experimental or investigational providing the specified criteria outlined in the patient's contract is met.

A methodology of reimbursement using points for each procedure and a conversion factor to establish an allowance for a given procedure code. BCBSKS does not utilize this system solely to establish MAPS.

Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.

The procedure by which a given claim is re-adjudicated to ensure correct processing has taken place before the appeals process begins. This request for retrospective review must be submitted to CSC within 120 days of the original processing date.

An amendment to a patient contract which may extend, reduce or exclude the benefits of the original contract. The provisions of a rider are stated specifically on a separate document that is attached to the patient's basic contract.

An illness or condition, otherwise eligible, for which any type of treatment is excluded from BCBSKS coverage.

Registered Physical Therapist.