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

primary source verification
A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.

prior authorization
In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review See also precertification.

prospective review
The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented.

RVS
See relative value scale.

screening programs
Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem. .

small group
Although each MCO's size limit may vary, generally a group composed of?two to 99 members for which health coverage is provided by the group sponsor.

specialty HMO
See specialty health maintenance organization.

specialty services
Healthcare services that are generally considered outside standard medical-surgical services because of the specialized knowledge required for service delivery and management.

standard of care
A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness or clinical circumstance.

Technology Evaluation Center
Pioneered the development of scientific criteria for assessing medical technologies through comprehensive reviews of clinical evidence. Assessments provide objective information to those who deliver and manage medical care The assessments are based on clinical and scientific evidence and evaluate whether a technology improves health outcomes.

termination with cause
A contract provision, included in all standard provider contracts, that allows either the MCO or the provider to terminate the contract when the other party does not live up to its contractual obligations.

termination without cause
A contract provision that allows either the MCO or the provider to terminate the contract without providing a reason or offering an appeals process.

unbundling
A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code for the entire procedure. The process of identifying and classifying the risk represented by an individual or group.

underwriting manual
A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.

URO
See utilization review organization.

utilization review (UR)
An evaluation of the medical necessity, appropriateness and cost-effectiveness of healthcare services and treatment plans for a given patient. .

WalkingWorks
Created by the Blue Cross and Blue Shield Association to help Blue Cross and Blue Shield companies motivate many of their 100 million members to integrate more walking into every day by tracking their steps via a walking log.