Glossary – Insurance and Medical Terminology – Common Terms | bcbs.com (2024)

A coverage plan under which an employer's group health plan, disability plan and workers' compensation program are merged, integrated or coordinated (depending on state regulations) into a single health benefit plan that covers employees 24 hours a day.

The application of managed care principles (techniques to reduce costs and improve the quality of health care) to 24-hour coverage.

A group of health care providers that agrees to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations.

A process in which a health care organization undergoes an evaluation 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.

The Patient Protection and Affordable Care Act, commonly called the ACA, was signed into law in 2010 to address health care access, quality and cost. The ACA was amended by the Health Care and Education Reconciliation Act on March 30, 2010.

The three characters preceding the subscriber identification number on Blue Cross and Blue Shield (BCBS) member ID cards. It identifies a member's local BCBS company or national account in order to properly route the claim.

A medical care center that provides a wide range of health care services, including preventive care, acute care, surgery and outpatient care, in a centralized facility.

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.

Maximum dollar amounts set by managed care organizations (MCO) that limit the total amount the health plan must pay for all health care services provided to a subscriber per year or in his/her lifetime.

A free-standing center that performs various types of surgery.

A service provided in connection with mental health, chemical dependency, or substance use disorders.

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 those best practices to equal or surpass the best outcomes.

The Blue Cross Blue Shield Association awards this designation to medical facilities that have demonstrated expertise in delivering quality health care in the areas of bariatric surgery, cardiac care, complex and rare cancers, spine surgery, gene therapy, maternal care, substance use treatment and recovery, transplants, and knee and hip replacement. The designation is based on evidence-based, objective selection criteria established with input from expert physicians and recommendations from medical organizations.

Leveraging the power of medical and pharmacy claims data from more than 200 million Americans, BHI delivers insights that empower health care organizations to improve patient care, reduce costs and optimize performance. Its team of data analysts, clinicians, IT experts and epidemiologists provide analytics, software-as-a-service and in-depth consulting to payers, providers, employers, medical device companies and other health care stakeholders. BHI is an independent licensee of the Blue Cross Blue Shield Association and carries the trade name of Health Intelligence Company, LLC.

A value-added discount program that provides BCBS members with discounts and content on health and wellness, family care, financial services, healthy travel and more. To see if your BCBS company participates in Blue365®, or for more information about the program, visit www.blue365deals.com.

A toll-free number, 1.800.810.BLUE, that members can use to locate providers in another Blue Cross and Blue Shield company's area. BlueCard Access® assists members who need a referral to a physician or health care facility in another location.

A toll-free number, 1.800.676.BLUE, for health care providers to verify BCBS membership and coverage information for patients. Calling BlueCard Eligibility will facilitate efficient payment for the provider.

Enables members to receive health care services wherever they live or travel, nationally or internationally. BlueCard® links participating health care providers and the independent BCBS companies across the country through a single electronic network for claims processing and reimbursem*nt.

A national program that offers members traveling or living outside of their BCBS Plan's area the PPO (preferred provider organization) level of benefits when they obtain services from a physician or hospital designated as a PPO provider.

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

The network comprising physicians, hospitals and other health care providers PPO members may choose to obtain the highest level of PPO benefits.

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

Established by the Balanced Budget Act, this program is designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

An itemized statement of health care 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 member or provider for payment of the costs incurred.

An application for payment of benefits under a health plan.

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

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.

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

A provision within a member's coverage that determines the amount paid by the insurer and the remaining amount paid by the member - for a health care service. A common coinsurance split could be 80/20, the insurer covers 80% of the medical expense and the member covers 20%.

An information system that incorporates membership data and provider reimbursem*nt arrangements and analyzes transactions according to contract rules.

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

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

A flat amount the member must pay before the insurer will make any benefit payments. The deductible is usually a set amount or percentage determined by the member’s contract and is set for a given period of time.

An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment.

A dental service plan that allows a member to use either a dental health maintenance organization’s (DHMO) network dentist or to seek care from a dentist not in the health maintenance organization's (HMO) network. Members choose in-network care or out-of-network care at the time they make their dental appointment and usually incur higher out-of-pocket costs for out-of-network care.

An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members.

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 coverage 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 for the patient. The direct care provider should file claims with the local BCBS company.

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

A program that evaluates whether drugs are being used safely, effectively and appropriately.

A computerized record of a patient's clinical, demographic and administrative data.

A voluntary health insurance program for federal employees, retirees and their dependents and survivors.

The fee determined by a MCO (managed care organization) 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.

A benefit payment system in which an insurer reimburses the group member or pays the provider directly for each covered medical expense after the expense has been incurred.

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.

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

A health maintenance organization (HMO) that contracts with a group of physicians with multiple specialties who are employees of the group practice. Also known as a group practice model HMO.

Health Insurance Portability and Accountability Act (HIPAA)

A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies and managed care organizations must satisfy in order to provide health insurance coverage to individuals and groups.

A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies and managed care organizations must satisfy in order to safeguard the privacy of patient and member data.

A type of health insurance plan. HMO plans have a defined network of providers you can use for care. Members typically need to choose a PCP as their main doctor and will need referrals to see a specialist. HMO plans may have lower premiums, deductibles, and copays compared to other health insurance plans.

Programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as preventive care programs or wellness programs.

Accounts that employers can establish for employees to reimburse a portion of their eligible family members' out-of-pocket medical expenses, such as deductibles, coinsurance and pharmacy expenses.

Allows members to save money in tax-advantaged accounts. Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free.

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 company as full payment for those services.

Specialized health care services that provide support to terminally ill patients and their families.

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

Traditional insurance, also known as Indemnity or Fee-for-Service, allows members to select any health care provider for services. Traditional insurance offers the most freedom of choice and control over health care, but benefits are maximized when using a participating BCBS company.

An individual or organization that offers care to patients from outside their local BCBS coverage area. Services may be provided from a single site or from multiple locations. The provider of services files any claims. BlueCard® applies if the provider of service is outside the member's BCBS service area and does not contract with the member's coverage. The member's location at the time of service is irrelevant. Often the patient and the indirect care provider are in different physical locations.

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 another number of members, depending on the managed care organization.

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

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

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

The MCO (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and authorization procedures. Medical advisory committees also review data regarding new medical technology and examine proposed medical policies.

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.

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

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 Advantage plans provide Medicare coverage through private health insurance companies approved to participate in the Medicare program. These plans can be HMOs, PPOs, regional PPOs or private fee-for-service plans.

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

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, extended-care facility, nursing home or an insured's home.

A Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part B coverage.

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

Medigap plans are sold by private insurance companies and are designed to assist with out-of-pocket costs (e.g., deductibles, copays and coinsurance) not covered by Medicare Parts A and B.

The broad range of activities that a MCO (managed care organization) and its employees undertake to support the delivery of the promised benefits to members and ensure member satisfaction.

A company that is owned by its members or policyowners.

An employer that has offices or branches in more than one location but offers uniform health care coverage to all employees.

A health maintenance organization (HMO) that contracts with multiple group practices of physicians or specialty groups.

A cost containment program that recovers money for health care services 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.

Dollar amounts set by MCOs (managed care organizations) that limit the amount a member has to pay out of pocket for particular health care services during a particular time period.

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.

A company that owns another company.

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

Information that relates to an individual's past, present or future physical or mental health or condition, or the past, present or future payment for the provision of health care to an individual, including demographic information, received from or on behalf of a health care provider, health plan, clearinghouse or employer, which either identifies the individual or could be reasonably used to identify the individual. It includes such information contained in any form or medium (electronic, paper, oral, etc.).

An individual's first name or first initial and last name in combination with any one or more of the following: 1) Social Security number; 2) driver's license number or state identification card number; or 3) account number, credit or debit card number, in combination with any required security code, access code or password that would permit access to an individual's financial account. PII does not include publicly available information that is lawfully made available to the general public from federal, state or local government records or widely distributed media. PII, as used in these Inter-Plan Programs Policies and Provisions, may have other meanings as assigned by various state laws related to data security breach notification.

Health insurance that covers the cost of your health care. Plans, also known as health insurance plans, or health plans, can vary in coverage, cost and terms.

A type of Health Benefit Plan that allows members to go outside the network for non-emergency care but may result in a lower level of benefits being paid by the Health Benefit Plan.

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

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.

A utilization management technique that requires a health care insurance 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.

Health care services provided to a health maintenance organization (HMO) member in exchange for a fixed, monthly premium paid in advance of the delivery of medical care.

See pharmaceutical cards.

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.

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

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

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

Preventive care programs designed to determine if a health condition is present, even if a member has not experienced symptoms.

Although the size limit of each MCO (managed care organization) may vary, a small group generally refers to a group containing at least two and less than a hundred members for which health coverage is provided by the group sponsor.

See Specialty health maintenance organization.

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

A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness or clinical circ*mstance.

The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.

A contract provision, included in all standard provider contracts, that allows either the MCO (managed care organization) or the provider to terminate the contract when the other party does not fulfill its contractual obligations.

A contract provision that allows either the MCO (managed care organization) or the provider to terminate the contract without providing a reason or offering an appeals process.

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.

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

An evaluation of the medical necessity, appropriateness and cost-effectiveness of health care services and treatment plans for a given patient.