We've compiled a list of common health care and health insurance related terms to help you better understand words commonly used in our industry and on our web site.
Terms appear in alphabetical order. To use the glossary, please choose the first letter of the term you would like to view.
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.