An independent representative licensed to sell and service Blue Cross and Blue Shield plans.
The amount we use to calculate our payment to in-network and out-of-network providers. It may be based on the contracted amount or another amount determined by us.
The amount paid by another health plan, such as Medicare or a spouse’s health plan.
An experienced health care professional (nurse, doctor or social worker) who works with patients, providers and plans to coordinate care for individual patients.
Information provided by a health care provider or a member to establish that medical services were provided. Blue Cross and Blue Shield network providers submit claims for their patients.
The percent of covered health care costs that a member pays after the total annual deductible is met.
The most coinsurance you pay out of your pocket in covered charges in a calendar year.
The contracted amount is the amount we have negotiated with hospitals, doctors and other health care providers. Coinsurance is calculated using either the provider’s billed charge or the contracted amount, whichever is less.
A payment, usually a fixed amount, that you make on a per-service basis.
The annual amount you pay toward eligible health care services each year before your coinsurance.
A spouse or a child who is enrolled as part of another member's health plan.
The conditions a person must satisfy to be covered by the health plan contract.
Services that are covered according to the health plan contract.
A notice sent from the health plan to the member describing the resolution of a claim. It includes services provided, amount billed, payment made and any costs that are the member’s responsibility.
A hospital, clinic, physician or other facility that provides health care services.
The amount or portion of the total charge for health care services that the health plan is responsible for.
Services provided in the home to aged, disabled, sick or convalescent people who don’t require institutional care. Services are provided by a home health agency, visiting nurse, or other hospital or community group.
A facility or program that provides supportive care for people who are terminally ill.
See Member ID card.
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
Coverage designed to reduce the risk that the contract holder would need to deplete his or her assets to pay for long-term care.
Documentation that provides medical necessity and coverage guidelines for our members.
Health care services and supplies that are evaluated as appropriate and necessary based on diagnosis and cost-effectiveness, and that are consistent with national medical practice guidelines on type, frequency and length of treatment.
Supplementary coverage, available to persons eligible for Medicare, to help pay remaining balances after Medicare has made payment.
A person covered by a health plan.
The identification number assigned to a member.
A card that identifies members of a plan. It lists the identification number, group number and effective date of the plan and includes important phone numbers.
The amount the member is responsible for of the total charge for health care services received.
The hospitals, physicians and other medical professionals who sign a contract with a health plan to provide care for its members.
Location, such as a clinic, where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury.
The period of time when an employee may change enrollment status or benefit plans, usually without evidence of good health or waiting periods.
Covered services that do not require admission to an inpatient setting.
The option to see health care providers who don’t have a contract with the health plan. When benefit plans include this option, members share more of the cost when receiving care from out-of-network providers.
The portion of health care costs that a member is responsible for, including co-pays, coinsurance, deductibles and non covered services.
The most a member must pay each year toward allowed health care costs. Once the out-of-pocket maximum is reached, the health plan pays 100 percent until the end of the calendar or benefit year. The out-of-pocket maximum does not include charges for non-covered services.
A facility or location where drugs and other medically related items and services are sold, dispensed or otherwise provided directly to patients.
A licensed doctor of medicine with full training in traditional medical practice. Physicians undergo a broad-based medical school education, extensive experience in residency and a comprehensive series of medical board examinations prior to being licensed.
PPO stands for preferred provider organization. PPOs are special arrangements between insurers and a network of hospitals, physicians and other health care professionals to pay for health care services. Benefits for covered services are paid at a higher percentage when PPO network providers are used.
A condition, whether physical or mental, for which diagnosis, care or treatment was recommended or received prior to coverage being effective. If a condition is pre-existing, it may not be covered for a specific period of time under some contracts.
The amount paid to a health plan company for providing coverage under a contract.
Basic or general health care usually provided by general practitioners, family practitioners, internists and pediatricians.
Any individual or group that provides a health care service, such as doctors, hospitals, group practices, nursing homes or pharmacies.
The amount that the cost of health care services is reduced based on a contract between the health plan and the provider.
Advanced approval from a primary care provider for a patient to see a specialist
The person whose employment is the basis for the health plan and who is responsible for payment of premiums.
The length of time during which no benefits are available for services related to a pre-existing medical condition.