Terms regarding health care, wellness and health insurance. Words appear in alphabetical order.
An entity or organization applying for health insurance coverage under terms of a specific contract - frequently contains more than one group.
A unique number assigned to an account by Capital BlueCross in order to administer health care coverage and associated administrative services.
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 (ASO)
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.
The date on which an account is re-enrolled each year subsequent to its initial enrollment.
A 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.
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 BlueCross.
Payments provided for services covered under the terms of the policy.
The limit or degree of services a person is entitled to receive based on his/her contract with a health plan or insurer.
Sum of money that is paid for specified services or for a calendar year or the contract lifetime.
The specified period of time during which charges for covered services must be incurred in order to be eligible for payment by the Plan. A charge for covered services is considered incurred on the date the service or supply was provided to a member.
BLUE CROSS AND BLUE SHIELD ASSOCIATION (BCBSA)
The national trade association of Blue Cross and Blue Shield Plans.
An entity that may underwrite or administer a range of health benefit programs.
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.
Request for payment for services provided to a member by a provider.
An application for payment of benefits under a health plan.
Claims which had their inception and for which the Plan becomes liable during a given period.
Claims paid by the Plan during a given period.
See definition for Consolidated Omnibus Budget Reconciliation Act.
A specific percentage of the provider's reasonable charge (PRC) for covered services that the member is required to pay and which is deducted from the PRC. Coinsurance is calculated based upon the amount of the PRC or the provider's actual charge, whichever is less, after the deductible and any applicable copayment amounts have been applied.
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.
CONSOLIDATED BENEFITS, INC. (CBI)
A for-profit, wholly owned insurance agency of Capital BlueCross.
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.
The contract, including group applications, riders and/or endorsements, if any, between the Plan and the group.
A numerical identification used to designate the holder of a specific contract.
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.
A specified dollar amount of eligible expenses that the member is required to pay for a specific covered service and which is deducted from the provider's reasonable charge before the determination of benefits payable under the contract is made.
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.
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.
A specified dollar amount of eligible expenses for covered services that must be incurred by the member before the Plan assumes liability for all or part of the remaining expense for covered services.
DENIAL OF BENEFITS
Rejection of a claim or part of it.
A spouse or eligible dependent children.
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.
The defined date a member becomes eligible for benefits under an existing contract.
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.
An employee who meets the eligibility requirement specified in the group contract to qualify for coverage.
Reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan.
An individual who meets the eligibility requirement specified in the provisions of the contract.
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 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 list of 10 categories of health services considered essential coverage by all health plans sold, both Marketplace health plans and private insurer health plans.
A summary statement that explains claim payment and/or the reason for denial of specific charges.
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.
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.
A chemically equivalent copy designed from a brand-name drug that has an expired patent.
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.
The individual representing the group and who often has the responsibility for assisting group members with benefit questions.
A numerical identification assigned to a group.
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 BENEFITS PACKAGE
The services and products (coverage) a health plan offers a group or individual.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
A federal act that protects people who change jobs, are self-employed, or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.
The health care services or supplies covered under the contract.
The Health Insurance Portability and Accountability Act of 1996.
IDENTIFICATION (ID) CARD
The card issued by the Plans to the member as evidence of membership. It shows name, number, types of coverage and effective date. Also called an ID card.
A charge is considered incurred on the date a member receives the service or supply for which the charge is made.
An agreement under which members are enrolled, billed personally, and pay subscription rates directly to the Plan.
The first time a particular group of members enroll for coverage.
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 BlueCross (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.
LENGTH OF STAY (LOS)
The length of an inpatient's stay in a hospital or other health facility.
Those benefits which health plans are required by state of federal law to provide to policyholders and eligible dependents.
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.
The programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.
A person who has been designated by the Social Security Administration as entitled to receive Medicare benefits.
The subscriber or dependent (i.e., all eligible persons covered under the contract).
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 BlueCross providing administrative services for employee health and welfare plans.
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.
This is a yearly limit placed on the amount of money you must pay from your own pocket your money for deductibles, coinsurance and copayments. The health plan you choose will have its own specific limit on out-of-pocket costs.
PARTICIPATING PROFESSIONAL PROVIDER
A professional provider with whom Capital BlueCross has a contract concerning payment for services covered by Capital BlueCross contracts.
A provider that has a contract with the Plan pertaining to payment for covered services rendered to a member. A participating provider may submit a claim for payment directly to the Plan.
PLACE OF SERVICE
The location where health services are rendered (i.e., office, home, hospital, etc.).
The amount of money the insured person (and/or the insured person's employer) pays the insurance company for enrollment in an insurance plan.
The preauthorization process involves clinical review of selected covered services prior to the service being rendered to assess the medical necessity of the service and appropriateness of level of care.
Description of the service provided.
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 Federal Marketplace are QHPs.
The amount of money per enrollment classification paid to a carrier for medical coverage. Rates are usually charged on a monthly basis.
The process of determining rates, or the cost of insurance, for individuals, groups or classes of risks.
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.
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.
The recommendation by a physician and/or health plan for a member to receive care from a different physician or facility.
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.
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.
Medical services sought independently by the member and not coordinated by the member's PCP.
The geographic area within which Capital BlueCross offers services.
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 company that is owned by another company, its parent.
The date that a group contract expires; or the date that a member ceases to be eligible.
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.
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A child for whom an adult (other than a parent) has been court appointed as a legal guardian.
A state-governed system designed to compensate employees for work-related injuries.
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