Copy of `BCBS - Health insurance terms`

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BCBS - Health insurance terms Category: Health and Medicine > American Health Care Date & country: 22/07/2014, USA Words: 117

accreditation
An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

ACD
See automatic call distributor.

ACF
See ambulatory care facility.

Alpha Prefix
Three characters preceding the subscriber identification number on Blue Cross Blue Shield ID cards required for routing claims. It identifies the member's Blue Cross Blue Shield Plan or national account.

ambulatory care facility (ACF)
A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.

ancillary services
Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy and occupational therapy, used to support diagnosis and treatment of a patient's condition.

behavioral healthcare
The provision of mental health and chemical dependency (or substance abuse) services.

Benchmarking
A method of planning and implementing quality management programs that consists of identifying the best practices and best outcomes for a specific process and emulating the best practices to equal or surpass the best outcomes.

BHI
See Blue Health Intelligence.

Blue 365
Addresses the health and lifestyle needs of consumers through unique partnerships and experiences designed exclusively for Blue365 members. A value added discount program that provides Blue members with discounts and content on health and wellness, family care, financial services, and healthy travel .

Blue Advocacy
The policy and legistlative division of the Blue Cross and Blue Shield Association representing The Blue System's views on healthcare insurance, advocacy, and policies on Capitol Hill.

Blue Health Intelligence
Provides greater healthcare transparency by delivering detail about healthcare trends and best practices, resulting in healthier lives and affordable access to safe and effective care. BHI brings together the healthcare experience of more than 54 million Blue Cross and Blue Shield members nationwide. Visit https://www.bluehealthintelligence.com/ today.

BlueCard Access
A toll-free 800 number, 1-800-810-BLUE, you and members can use to locate providers in another Blue Cross or Blue Shield Plan's area. This number is useful when you need to refer the patient to a physician or healthcare facility in another location.

BlueCard Eligibility
A toll-free 800 number, 1-800-676-BLUE, for providers to verify membership and coverage information on patients from other Blue Cross Blue Shield Plans. Calling BlueCard Eligibility will facilitate quicker payments.

BlueCard
Enables members to receive healthcare services wherever they live or travel, nationally or internationally. BlueCard links participating healthcare providers and the independent Blue Cross and Blue Shield companies across the country through a single electronic network for claims processing and reimbursement .

BlueCard
A national program that offers members traveling or living outside of their Blue Cross Blue Shield Plan's area the PPO level of benefits when they obtain services from a physician or hospital designated as a PPO provider.

BlueCard
Carries an ID card with this identifier on it. Only members with this identifier can access the benefits of BlueCard PPO.

BlueCard
The network comprising those physicians, hospitals and other healthcare providers PPO members may elect to use to obtain the highest level of PPO benefits.

BlueCard
A doctor, hospital or other healthcare entity enrolled in a network of designated PPO providers.

BlueDistinction
A designation awarded by the Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality healthcare in the areas of: bariatric surgery, cardiac care, complex and rare cancers, knee and hip replacement , spine surgery and transplants. The designation is based on rigorous, evidence-based, objective selection criteria established with input from expert physicians and recommendations from medical organizations .

BlueWorks
The annual BlueWorks Awards program is designed to advance that mission by recognizing the single Blue Cross and/or Blue Shield company that best demonstrates taking a leadership role in transforming the quality, affordability and delivery of care. BlueWorks entries are reviewed by the Harvard Medical School Department of Health Care Policy and independent judges from key medical societies for their innovation, scope, approach and impact on healthcare delivery in Blue companies' local markets.

Call abandonment rate
A measure of how often members hang up before receiving assistance when they make telephone calls to a company and are put on hold.

claim
An itemized statement of healthcare services and their costs provided by a hospital, physician's office or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

claim form
An application for payment of benefits under a health plan. International claim forms are located here. For other claim forms, please see your local Blue Cross and Blue Shield companies.

claims investigation
The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.

clinic model
See consolidated medical group.

clinic without walls
See group practice without walls.

clinical practice guideline
A utilization and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case.

CMP
See competitive medical plan.

COBRA
See Consolidated Omnibus Budget Reconciliation Act.

coding errors
Documentation errors in which a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.

Coinsurance
A provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 percent. Any additional costs are paid by the member out of pocket.

contract management system
An information system that incorporates membership data and provider reimbursement arrangements and analyzes transactions according to contract rules.

coordinated care plans (CCPs)
The Medicare+Choice delivery option that includes HMOs (with or without a point-of-service component), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs).

copayment
A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered. .

Deductible
A flat amount the member must pay before the insurer will make any benefit payments.

dental PPO
See dental preferred provider organization. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

DHMO
See dental health maintenance organization. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.

Direct Care Provider
An individual or organization that offers care directly to the member. The direct care provider is in the same physical location as the member and offers care to patients from within the local Plan's service area Some examples are: (1) a provider who physically examines the patient, (2) a lab that performs the blood draw from a patient, or (3) a technician who fits a prosthetic limb to the patient. The direct care provider should file claims to the local Blue Plan.

disease management
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.

disease state management
See disease management.

drug utilization review (DUR)
A review program that evaluates whether drugs are being used safely, effectively, and appropriately.

electronic medical record (EMR)
A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record.

EMR
See electronic medical record. .

ERISA
See Employee Retirement Income Security Act.

fee schedule
The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum or capped fee.

Flexible Spending Account (FSA)
Allows members to use pre-tax dollars for certain eligible medical and dependent care expenses. Members fund their FSAs with contributions that come out of their paycheck.

formulary
A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that are to be used by an MCO's providers in prescribing medications.

Good Health Club℠
The Good Health Club promotes healthy choices and behaviors in children through fun, effective, age-appropriate communications. The Good Health Club uses a group of animated characters to teach kids to: Eat 5 servings of fruits and veggies every single day, limit screen time to 2 hours or less, get at least 1 hour of physical activity and limit sweetened drinks to 0.

group model HMO
An HMO that contracts with a multi-specialty group of physicians who are employees of the group practice. Also known as a group practice model HMO.

HIPAA
See Health Insurance Portability and Accountability Act.

HMO
See health maintenance organization.

Hold Harmless
An agreement with a provider not to bill the subscriber for any difference between billed charges for covered services (excluding coinsurance) and the amount the provider has contractually agreed with a BCBS Plan as full payment for those services.

hospice care
A set of specialized healthcare services that provide support to terminally ill patients and their families.

immunization programs
Preventive care programs designed to monitor and promote the administration of vaccines to guard against childhood illnesses, such as chicken pox, mumps, and measles, and adult illnesses, such as pneumonia and influenza.

Indemnity and Traditional Insurance
Traditional insurance provides members with the most freedom of choice, and offers the most control over your healthcare. Traditional insurance, also known as Indemnity or Fee-for-Service, allows members to select any healthcare provider However, benefits are maximized when using a participating Blue Cross and Blue Shield company.

large group
A large pool of individuals for which health coverage is provided by the group sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number of members, depending on the MCO.

managed care
The integration of both the financing and delivery of health-care within a system that seeks to manage the accessibility, cost and quality of that care.

managed dental care
Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.

MCO
See managed care organization.

Medicaid
A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

medical advisory committee
The MCO committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation, and changes in authorization procedures, reviews data regarding new medical technology and examines proposed medical policies.

medical director
The health plan physician executive who is responsible for the quality and cost-effectiveness of the medical care delivered by the plan's providers. Also known as a chief medical officer.

medical group practice
See consolidated medical group.

medical underwriting
The evaluation of health questionnaires submitted by all proposed plan members to determine the insurability of the group.

Medicare
A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.

Medicare Part A
The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.

Medicare Part B
The Medicare component that provides benefits to cover the costs of physicians' professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home or an insured's home.

Medicare SELECT
A Medicare supplement that uses a preferred provider organization to supplement Medicare Part B coverage.

Medicare supplement
A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.

Medigap policies
Individual medical expense insurance policies sold by state-licensed private insurance companies.

member services
The broad range of activities that an MCO and its employees undertake to support the delivery of the promised benefits to members and to keep members satisfied with the company.

MHS
See Military Health System.

MSO
See Management Services Organization.

mutual company
A company that is owned by its members or policyowners.

My Blue Community℠
Online community that empowers members to make informed appropriate health choices based on either experiences from other healthcare consumers with similar circum?stances or expert advice.

National Account
Employer group that has offices or branches in more than one location, but offers uniform coverage of benefits to all of its employees.

National Walk@Lunch Day
An extension of the WalkingWorks

network model HMO
An HMO that contracts with more than one group practice of physicians or specialty groups.

Other Party Liability (OPL)
A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions. Includes coordination of benefits, Workers' Compensation, subrogation and no-fault auto insurance.

out-of-pocket maximums
Dollar amounts set by MCOs that limit the amount a member has to pay out of his/her own pocket for particular healthcare services during a particular time period.

outpatient care
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

PACE
See Programs of All-inclusive Care for the Elderly.

parent company
A company that owns another company.

PCCM
See primary care case manager.

PCMH
See Patient-centered medical home.

PCP
See primary care provider.

personal care physician
See primary care provider.

pharmaceutical cards
Identification cards issued by a pharmacy benefit management plan to plan members. These cards assist PBMs in processing and tracking pharmaceutical claims Also known as drug cards or prescription cards.

PHO
See physician-hospital organization.

Plan
Refers to any Blue Cross and/or Blue Shield Plan.

Point of Service (POS)
A healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross and Blue Shield Plan?s network or seek medical care outside of the network.

pooling
The practice of underwriting a number of small groups as if they constituted one large group.

PPO
See preferred provider organization.

preadmission testing
A utilization management technique that requires plan members who are scheduled for inpatient care to have preliminary tests, such as X-rays and laboratory tests, performed on an outpatient basis prior to admission. .

precertification
A utilization management technique that requires a plan member or the physician in charge of the member's care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.

pre-existing condition
In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.

prepaid care
Healthcare services provided to an HMO member in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.

primary care
General medical care that is provided directly to a patient without referral from another physician. It is focused on preventive care and the treatment of routine injuries and illnesses.

primary care physician
See primary care provider.