Access standards

Accessibility of health care services.


An entity or organization applying for health insurance coverage under terms of a specific contract - frequently contains more than one group.

Account number

A unique number assigned to an account by Capital Blue Cross in order to administer health care coverage and associated administrative services.

Account upgrade

Change your non-member account to a member account.


The process by which an agency or organization evaluates and recognizes a program of study or an institution as meeting certain predetermined standards.

Administrative services only

An arrangement under which an insurance carrier or independent organization handles, for a fee, the administration of claims, benefits, and other administrative functions for a self-insured group.

Advanced Premium Tax Credit

Advanced Premium Tax Credit (also premium tax credit, premium subsidy) Federal dollars to help mid- to lower-income Americans and their families pay the premium for health insurance. Getting subsidy money depends on family size and income levels set by the Federal Government. Premium subsidy money is not available to those covered by group health insurance or Medicaid.

After hour care

Medical care provided for urgent or emergency situations after regular office hours.

Aggregate deductible

For family coverage, the service provided to each member of your family applies toward the same deductible. You must meet the deductible before your benefits kick in.

Allowable amount

The maximum amount your plan will pay for covered health services.

Anniversary date

The date on which an account is re-enrolled each year subsequent to its initial enrollment.


Written request questioning the Plan's adverse determination affecting a member's claim or eligibility.


The written request for coverage under a contract on a form furnished by the Plan.

Association group

A group formed from members of a trade or a professional association for group insurance under one master health insurance contract. To qualify as an association group, the group must meet and maintain the underwriting criterion of Capital Blue Cross.



Payments provided for services covered under the terms of the policy.

Benefit levels

The limit or degree of services a person is entitled to receive based on his/her contract with a health plan or insurer.

Benefit maximum

Sum of money that is paid for specified services or for a calendar year or the contract lifetime.

Benefit period

The span of time you are covered under your health plan. It is often a full year.


Health and wellness discounts for members.


As a member of a Blue Plan, you can receive health benefits in another Blue Plan's service area. Blue Cross Blue Shield companies and providers around the world are linked to one network.

Blue Cross Blue Shield Association (BCBSA)

The national trade association of Blue Cross and Blue Shield Plans.

Blue Cross Blue Shield Global Core

Get health coverage for traveling or living abroad.

Body mass index (BMI)

A measure of body fat based on height and weight.

Brand drug

A drug that has a trade name and can be produced and sold by only one company.


Care consultant

The professional(s) responsible for an episode of care.


An entity that may underwrite or administer a range of health benefit programs.

Case management

The planning, processing, and monitoring of coordinated care.

Case manager

A specially trained professional who works with you, your family, and your doctors to coordinate your care.

Certificate of coverage

A full explanation of your health plan benefits.

Challenge questions

An extra layer of security for your private account.


The amount billed by a professional provider or by a supplier for covered services.

Children's Health Insurance Program (CHIP)

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


A request for payment for services sent to you or your insurer by a doctor or hospital.

Claim form

An application you submit to your insurer for payment of health care costs.

Claim status

Indicates where a claim is in the payment or denial process.


A request for payment for services sent to you or your insurer by a doctor or hospital.

Claims incurred

Claims which had their inception and for which the Plan becomes liable during a given period.

Claims paid

Claims paid by the Plan during a given period.

Closed formulary

A list of drugs covered under your prescription plan that limits access to certain drugs.


See definition for Consolidated Omnibus Budget Reconciliation Act.


The percentage of health care costs you are responsible for paying after your deductible is met.

Comprehensive major medical (CMM)

A fee-for-service plan that allows you to see any doctor you choose. Charges are sent to your insurer, who decides what it will pay based on defined coverage levels.

Concurrent review

An assessment of a member's inpatient hospital admission that is performed by a specially trained nurse via telephone or on-site in the hospital. The purpose of the concurrent review nurse is to evaluate appropriateness of care, treatment, continued hospital stay, offer alternative placement options and provide assistance and guidance with discharge planning.

Condition management

Coordinated care interventions, education, and communication for conditions that require significant self-care.


Secret or private.

Consolidated Benefits, Inc. (CBI)

A for-profit, wholly owned insurance agency of Capital Blue Cross.

Consolidated Omnibus Budget Reconciliation Act of 1985

Federal legislation that requires employer-sponsored group health plans to allow previously covered employees, spouses and dependents who might otherwise lose group health care benefits to elect to continue their benefits.


An agreement between an insurance company and its customer.

Contract number

A numerical identification used to designate the holder of a specific contract.

Contract year

The period of 12 consecutive months following the effective date of any contract and each subsequent 12-month period thereafter during the time the contract is in effect.

Coordination of benefits (COB)

Provisions and procedures used by insurers or third party payers to avoid duplicate payment for losses covered under more than one policy or contract.


The fixed amount you pay each time you receive covered health care services.


The division of payments between you and your insurer. Your contribution typically includes deductibles, coinsurance, and copayments.


The extent of benefits provided under a member's contract issued by the Plan.

Coverage effective date

The date enrollment begins or changes for a contract or member.

Covered service

Your health plan will cover some portion of these services.


A process of review to approve a provider who applies to participate in a health plan. Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.


Date of service

The date on which health care services were provided to the member.


The amount you pay for health care services before your plan starts to pay.

Denial of benefits

Rejection of a claim or part of it.

Dental coverage

Health insurance for visits to the dentist.


A spouse or eligible child who is covered under your health insurance.

Description of service

The type of services or products received from a provider.

Diagnostic radiology

The use of imaging exams and procedures to diagnose a patient.

Digital health tools

Online programs that help you make changes to achieve your health goals.

Durable medical equipment (DME)

Equipment and supplies ordered by a doctor for everyday or extended use, including oxygen equipment, crutches, blood testing strips, and more.


Effective date

The date a contract takes effect.

Electronic data interchange (EDI)

The application-to-application interchange of business data between organizations using a standard data format.

Eligibility date

The defined date a member becomes eligible for benefits under an existing contract.

Eligible dependent

A dependent of a covered employee who meets that requirements specified in the group contract to qualify for coverage and for whom premium payment is made.

Eligible employee

An employee who meets the eligibility requirement specified in the group contract to qualify for coverage.

Eligible expenses

Reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan.

Eligible person

An individual who meets the eligibility requirement specified in the provisions of the contract.

Emergency care

Medical care provided in life-threatening situations.

Employee Retirement Income Security Act (ERISA)

A comprehensive federal statute governing employee benefit and pension plans.


To agree to participate in a contract for benefits from an insurance company or health maintenance organization. A person who enrolls is an enrollee or member.

Essential benefits

Essential Health Benefits (also Minimum Value Benefits) A minimum level of health coverage set by the Affordable Care Act that must be offered by all individual and employer group health plans. A summary statement that explains claim payment and/or the reason for denial of specific charges.

Evidence of coverage

An agreement or certification that contains information regarding coverage and other rights to which an enrollee is entitled.


The marketplace where individuals, families, and small businesses can shop for health insurance. Sometimes called the 'Federal Marketplace' in states that partner with the federal government.

Explanation of benefits (EOB)

A statement from your insurer explaining what medical services were paid on your behalf.


Federal employee health benefits program

A voluntary health insurance program administered by the Office of Personnel Management (OPM) for federal employees, retirees, and their dependents and survivors.

Federal Employee Program (FEP)

A health care coverage program designed for Federal employees and their families.

Federal marketplace

The place where individuals, families, and small businesses can shop for health insurance. Also known as the 'exchange'.

Finalized claim

When a claim's status is 'paid' or 'denied'.

Flexible spending account (FSA)

Your employer deducts funds from your pay to be used for qualified out-of-pocket health care or dependent care expenses. You don’t pay taxes on these funds.


A list of drugs covered under your prescription plan.


Intentional misrepresentation by either providers or consumers to obtain services or payment for services. Fraud may include deliberate misrepresentation of need or eligibility; providing false information concerning costs or conditions to obtain reimbursement or certification; or claim payment for services which were never delivered or received.


Generic drug

A copy of a brand drug whose patent has expired.

Generic substitution

The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary.


A collection of eligible employees who are employed by a single employer (i.e., corporation, partnership, sole proprietorship, professional corporation, etc.), or are members of a health and welfare fund (union organization) and who qualify as members under the contract in accordance with the enrollment regulations of the Plan.

Group administrator

The individual representing a group who often assists group members with benefit questions.

Group ID number

A numerical identification assigned to a group.


HCFA 1500

A universal form, developed by the governmental agency known as Health Care Financing Administration (HCFA), for providers of service to bill professional fees to health carriers.

Health assessment

A questionnaire that gives you a personalized, confidential health report and recommendations.

Health benefits package

The services and products (coverage) a health plan offers a group or individual.

Health coverage tax form

Report your coverage for the prior year. This form is used on your tax return to verify that you and your dependents have minimum essential coverage.

Health education

Teaching health improvement and/or awareness.

Health Insurance Portability and Accountability Act (HIPAA)

Federal standards we follow to ensure your health information is protected. What to know more? Read a full summary.

Health maintenance organization (HMO)

A health plan in which your care must be coordinated by your primary care physician (PCP).

Health reimbursement arrangement (HRA)

An employer-funded group health plan that helps you pay for qualified out-of-pocket health care costs.

Health savings account (HSA)

A savings account for those enrolled in a Qualified High Deductible Health Plan. You and your employer can contribute. You can use these funds to pay for qualified out-of-pocket medical expenses or to save for retirement. You own the account and don’t pay taxes on deposited funds or withdrawals that meet IRS requirements.

Health services

The health care services or supplies covered under the contract.


A nonprofit organization that provides Capital Blue Cross members with tools and resources to help them make better health decisions.

Healthwise® knowledgebase

A search tool from Healthwise that Capital Blue Cross members can use to answer their health questions.

Healthy Blue Rewards

The Capital Blue Cross wellness program that provides education and incentives for living a healthy lifestyle.


ID card

A card issued to each member of a health care plan, often required by your doctor or hospital prior to providing care


A charge is considered incurred on the date a member receives the service or supply for which the charge is made.

Individual coverage

A health plan purchased by individuals to cover themselves and their immediate families.

Ineligible amount

The portion of the amount billed that was not covered or was ineligible for payment under your plan.

Initial enrollment

The first time a particular group of members enroll for coverage.

In-network provider

Doctors, hospitals, and other providers contracted with your health plan to provide care.

Interactive tools

Online resources that respond to your activity.

Itemized bill

Bill indicating patient's name, provider's name, date of each service, type of each service and the charge for each.


Joint Commission on Accreditation of Health Care Organizations (JCAHO)

A private, nonprofit organization whose purpose is to encourage the attainment of uniformly high standards of institutional medical care.


Keystone Health Plan® Central (KHPC)

A Health Maintenance Organization (HMO), owned by Capital Blue Cross (subject to regulatory approval), offering the Keystone Health Plan Central HMO product.



Termination of a policy upon the policy holder's failure to pay the premium within the time required.

Legal guardian

The legal caretaker of a child who makes health care decisions for him or her.

Length of stay (LOS)

The length of an inpatient's stay in a hospital or other health facility.


The way in which a person or group lives.

Lifetime maximum

A cap on the total lifetime benefits you may get from your insurance company. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.


Mail-order pharmacy

A pharmacy that sends prescription drugs via mail.

Mailing address

The location where your mail is delivered.

Managed care

A health care system that manages accessibility, cost, and quality of care.

Mandated benefits

Those benefits which health plans are required by state of federal law to provide to policyholders and eligible dependents.

Mandatory maintenance choice

A prescription program that gives you the choice of filling your maintenance prescriptions through mail or pick-up.


A federal program administered and operated individually by participating state and territorial governments which provides medical benefits to eligible low income persons needing health care. The costs of the program are shared by the federal and state governments.

Medical care

Medical services received from a health care provider.

Medical condition

An injury, ailment, disease, illness, or disorder.

Medical policy

The guidelines for health care coverage decisions, which vary by insurer and plan.


The programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.

Medicare beneficiary

A person who has been designated by the Social Security Administration as entitled to receive Medicare benefits.


All eligible persons covered under your contract (i.e. a subscriber or dependent).

Member authorization

Permission for a designated person to view and receive information about a member's health.

Member ID number

A numerical identification assigned to a member.

Member message center

An inbox with private messages about your health and coverage, available after signing in to your secure member account.

My account

A tool that allows you to update your profile and preferences, available after signing in to your secure member account.


National Association of Insurance Commissioners (NAIC)

The association of insurance commissioners of various states formed to promote national uniformity in the regulation of insurance.

National Claims Administrative Services (NCAS)

A for-profit incorporated subsidiary of Capital Blue Cross providing administrative services for employee health and welfare plans.


The doctors, hospitals, or other health care providers contracted with your health insurer to provide health care services.

Nicotine cessation

Quitting smoking.

Non-participating provider

A doctor, hospital, or other health care provider who is not contracted with your health insurer to provide health care services.

Non-preferred drugs

Brand drugs not included in your plan's list of covered drugs.

Nurse chat

Speak to a live registered nurse online.


Office visit

Physician services provided in an office setting.

Open enrollment period

A period when new members in a health benefit program have an opportunity to select an alternate health plan being offered to them.

Open formulary

Unrestricted access to prescriptions, whether they are generic, brand, preferred, or non-preferred.

Opt in

Give Capital Blue Cross permission to communicate with you.

Opt out

Tell Capital Blue Cross not to communicate with you.

Out-of-pocket maximum

The maximum amount that you or your family pay during a benefit period.

Out-of-network provider

A doctor, hospital, or other health care provider who is not contracted with your health insurer to provide health care services.


Participating provider

A doctor, hospital, or other health care provider contracted with your health insurer to provide health care services.

Pay my premium

An option to pay your monthly health insurance bill online.

Pending claim

Indicates that a claim is not yet paid or denied.

Personal health advisor

A health professional who gives you extra support to make healthy decisions and lifestyle changes.

Pharmacy benefit administrator

A third-party administrator (TPA) of prescription drug programs.

Physician of choice

A doctor you choose to manage and coordinate your care for PPO, traditional, and non-managed-care insurance.

Place of service

The location where health services are rendered (i.e., office, home, hospital, etc.).


Capital Blue Cross.

Plan of care

Provides direction on the medical procedures, recovery time, and resources you will receive.

Point of service (POS)

A plan design that allows you to go outside your network for non-emergency care, but may mean a lower level of coverage paid by your insurer.


An approval given prior to health care services to make sure they are medically appropriate. Some medical and therapy services, and all non-emergency inpatient hospital services require preauthorization.

Precious Baby Prints

Capital Blue Cross' maternity care program.

Preference Center

A tool for you to control how Capital Blue Cross communicates with you, available after signing in to your secure member account.

Preferred drugs

Brand drugs included on your plan's list of covered drugs.

Preferred provider organization (PPO)

A health plan that allows you to choose any doctor or hospital in the network.


The first three characters of your Member ID.


The amount you and/or your employer pay each month for health insurance.


A medicine or treatment authorized by a doctor.

Preventive care

Routine check-ups, screenings, vaccines, and other health care services to keep you healthy and detect any problems early.

Price checker

A tool that allows members to compare the price of a prescription drug.

Primary address

The location where you live full-time.

Primary care physician (PCP)

A doctor you choose to manage and coordinate your care. In a health maintenance organization (HMO) plan, your PCP authorizes referrals to specialists and hospitals.


A specific service (often a surgical operation) provided by your doctor.

Provider directory

A list of participating providers that are classified by type, specialties, credentials, demographics, and service locations.


Qualified health plan (QHP)

An insurance coverage plan that is certified by the federal or a state marketplace exchange as providing essential health benefits and affordable health care coverage. All health plans sold on the health insurance marketplace are QHPs.

Qualified high deductible health plan (QHDHP)

A health plan that meets all IRS requirements to enable you to contribute to a Health Savings Account (HSA). This allows you to pay for qualified medical expenses with money free from federal taxes, or to grow the account tax-free for use during retirement.



The amount of money per enrollment classification paid to a carrier for medical coverage. Rates are usually charged on a monthly basis.

Rate your doctor

Provide feedback on your doctor in the provider search tool, available after signing in to your secure member account.


The process of determining rates, or the cost of insurance, for individuals, groups or classes of risks. 

Reconstructive surgery

A procedure performed to restore a bodily function, or to correct a deformity resulting from disease, injury, trauma, congenital anomalies or developmental abnormalities, or previous medically necessary treatment (e.g., surgery, radiation therapy). The characteristics to be corrected are considered to be outside the range of normal. Examples of such conditions include cleft lip, deforming birthmarks and burn scars.

Recurring condition

A condition which causes successive periods of care that are separated:

  • By one or more days; and
  • By less than 180 days.

Successive periods of care due to a recurring condition are not subject to a new elimination period.


The process of enrolling an individual member as new following termination of coverage. Because of the time lapse between termination and re-enrollment, continuity of benefits is lost. Members are assigned new effective dates and may be subject to contract waiting periods.


A recommendation from a doctor or insurer for you to receive care from a different doctor or hospital.

Referring physician

A doctor who recommends or orders an item or service (e.g. lab tests, medical equipment, specialty services) that will be provided and billed by another health care provider.

Registered nurse (RN)

A nurse who has graduated from a formal program of nursing education (diploma school, associate degree or baccalaureate program) and is licensed by the appropriate state authority.


(a) Restoration of a disabled person to a meaningful occupation. (b) A provision in some disability policies that provides for continuation of benefits or other financial assistance while a disabled insured is retraining or attempting to resume productive employment.


The resumption of coverage under a policy which has lapsed.


The practice of one insurance company having insurance from a second company for the purpose of protecting itself against part or all of the losses it might incur in the process of honoring the claims of its policyholders.


A refusal to accept an application or a refusal to pay a claim.


Continuance of coverage under a policy beyond its original term by the acceptance of a premium for a new policy term.

Renewal period

A set, hospital-free period of time which must be satisfied after a hospital admission before a member's contracted benefit days renew.


Accounts set up to report the liabilities faced by an insurance company under outstanding insurance policies. The company sets the amount of reserves in accord with its own estimates, state laws and recommendations of supervisory officials and national organizations. Reserves are obligated amounts and have four principle components; reserves for future benefits; and other reserves for various special purposes, including contingency reserves for unforeseen circumstances.


That portion of the cost of a medical benefit program which is kept by the insurance company or health plan to cover internal costs or to return a profit. In addition to administrative costs, our total retention includes other elements such as risk, contingency, nongroup subsidy, etc.


The premium/dollars received by the health plan from the employer group(s) for health care and administrative services. See also premium.


The amounts earned from a company's sales of products and services to its customers.


A provision added to a member contract whereby the scope of its coverage is increased or restricted.

Routine eye care

Consists of eye examination or refractions reported without a symptomatic condition, disease, injury or defect related to the eye.


Secure mail

An encrypted message usually containing private health information, available after signing in to your secure member account.

Secure member account

A private area of where you can manage your account, available after signing in with your username and password.

Selectively closed formulary

A list of drugs covered under your prescription plan that gives you access to certain generic and brand drugs.


Medical services sought independently by the member and not coordinated by the member's PCP.

Service area

The geographic area within which Capital Blue Cross offers services.

Service type

A code used to classify a service or benefit.


A text message sent to your cell phone.

Social security number

A nine-digit number assigned to citizens and some temporary and permanent residents, used to track income and determine benefits.

Special Enrollment Period

A Special Enrollment Period (SEP) is a 60-day period during which an eligible individual may enroll in an individual plan or change from one plan to another due to qualifying life events. These events include change in family status, loss of plan, or other hardships.


A doctor who focuses on a specific area of medicine or group of patients.


A company that is owned by another company, its parent.


The primary member of your health plan, responsible for paying monthly premiums (other members are called dependents).

Suffix (00, 01, 02)

The last two numbers that appear at the end of the Member ID number.

Summary of benefits

An easy-to-understand summary of a health plan's benefits and coverage.

Symptom checker

A tool that helps you diagnose ailments or health conditions, available after signing in to your secure member account.


Tax form 1095B

Report your coverage for the prior year. This form is used on your tax return to verify that you and your dependents had minimum essential coverage.

Temporary evidence of coverage

Provides proof that you have coverage with an insurer.

Termination date

The date that a group contract expires; or the date that a member ceases to be eligible.

Traditional insurance

Also known as fee-for-service insurance, traditional plans allow you to choose any doctor or hospital. Benefits are best when using a participating provider.

Treatment cost estimator

Estimate costs for various health care services, available in the provider search tool after signing in to your secure member account.


Urgent care

Prompt medical attention for situations that are not emergencies.

Urgent care provider

A doctor who provides prompt medical attention for situations that are not emergencies.


The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time. Usually expressed as the number of services used per year or per 100 or 1,000 persons eligible for the service.


Video conference

An online meeting that allows participants to communicate using audio and video.


Health care made available to you over a phone, tablet, or computer.

Vision coverage

Health insurance for visits to the eye doctor.



A child for whom an adult (other than a parent) has been court appointed as a legal guardian.

Workers' compensation

A state-governed system designed to compensate employees for work-related injuries.