Glossary of Health Insurance Terms

See "Referral Specialist."

See "Relative Value Units."

See "Final level appeal."

The insurer who processes the services after the primary insurance carrier has made their adjudication of the services.

See "Internal Control Number."

Treatment, care or item provided to a patient. See "HCFA Common Procedure Coding System" and "Procedure Code."

The area in which the provider practices or has their business.

Under this program the patient pays 50 percent of the allowed charge on covered services up to a designated amount. BCBSKS pays the other 50 percent. The patient's premiums are usually less costly with this plan.

The expense incurred under a patient's contract that is transferred to another contract. For this to happen, the expenses and contract effective dates must be in the same contract year.

See "Blue Shield of Kansas" and "Anthem Blue Cross and Blue Shield, Inc."

Only the member/member -patient is covered as opposed to family coverage where the member/member, the spouse, and dependent children are covered.

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

The State of Kansas department that oversees Outpatient Substance Abuse Facility licensing. This is also the department that regulates the state Medicaid program.

See "LSP."

A healthcare plan offering a program that encompasses benefits and/ or medical services outside of normal benefits.

See "Self Referral Option."

See "Social and Rehabilitation Services."

Social Security Administration.

The average charge made by BCBSKS contracting providers for a given service.

The group of BCBSKS employees that are responsible for overseeing the running of the company. This committee is comprised of the President and Vice-Presidents.

See "Individual stop loss."

See "Individual stop loss."

An accepted method of recordkeeping to support the medical necessity and actual services rendered to our members/members -patients. See "Medical Recordkeeping."

BCBSKS' right to recoup monies paid when another insurer has legal responsibility for payment of expenses. The substitution of one for another as creditor so that the new creditor succeeds to the former's rights or obligations.

The department at BCBSKS that has responsibility of billing and setting up the eligibility of our BCBSKS members -patients.

See "Medicare Part B."

A request for payment that has been delayed for payment until further development can occur.

See "Suspended claim."

See "Technical Component."

The charge for performance of mechanical operating procedures, including cost of materials and use of equipment, associated with securing an x-ray or a laboratory test specimen.

The provision of consultant services by off-site physicians to health care professionals on the scene by means of closed-circuit television; the ability of health care providers to examine patients, not in person, but by means of a computer screen.

See "Blue Plan."

An organization that is outside of the insuring organization that handles the administrative duties and sometimes utilization review. Third party administrators are used by organizations that fund the health benefits but do not find it cost effective to administrate the plan themselves.

An insurance carrier or governmental agency that reimburses for health care services provided to a patient. The provider and the patient are the first two parties of the delivered service.

Medicaid, which is a federally and state funded welfare program.

Medicare, which is a federally funded program for those 65 and over and those disabled.

See "Type of Service."

A pre-paid fee-for-service health plan that gives members maximum freedom of choice, allowing them to seek medical care from any healthcare provider without reduction of benefits.

Professional service rendered by a provider.

A written report showing the provider's recommended course of tests, modalities, medicines, etc. See "Medical recordkeeping."

The military's integrated health care deliver system. The TRICARE system includes the Civilian Health and Medical Program of the Uniformed Services - CHAMPUS. TRICARE gives the regional military treatment facilities control of health care deliver costs and purchasing. The TRICARE system splits U.S. military bases into 12 designated regions. One major military health care facility within each of the regions is designated as the "lead agent," which is responsible for organizing and maintaining an integrated delivery network, including civilian providers. BCBSKS participates in TriWest, which is the deliverer of care for this region.

See “TRICARE.”

See "Treatment."

See "Benefit, type of."

A one-digit code used with the procedure code to identify a specific category of service.

Uniform Bill 1992. The claim form used to bill facility charges to Medicare Part A and Blue Cross of Kansas. It replaced the UB-82.

See "Uniform Claim Form."

See "Usual, Customary and Reasonable."

The separating of a procedure into its many components, resulting in payment for each component rather than a global price for the entire procedure. One or more components of a procedure may be broken out and paid separately. See "Content of Service" and "Bundling."

See "Unlisted Procedure."