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555-555-0199@example.comUsed as an alternative to retail pharmacies, members can order and refill their prescriptions via postal mail, Internet, fax, or telephone. Once filled, the prescriptions are mailed directly to the member’s home.
555-555-0199@example.comAlso known as a formulary, this is a list of certain brand name and covered generic prescription drugs. The preferred drug list was developed and is maintained by the CareFirst BlueCross BlueShield Pharmacy and Therapeutics Committee, which is made up of a group of physicians and pharmacists that practice in the CareFirst BlueCross BlueShield region. CareFirst BlueCross BlueShield may change this list from time to time to provide the most cost-effective and complete prescription drug options to members.
555-555-0199@example.comA medication that is anticipated to be taken regularly for several months to treat a chronic condition such as diabetes, high blood pressure and asthma.
555-555-0199@example.comA term that describes procedures performed on structures of the body to improve or restore bodily function or to correct deformity resulting from disease, trauma or previous therapeutic intervention.
555-555-0199@example.comA benefit option in which a member pays a lower copay for generic drugs (Tier 1), a higher copay for preferred brand name drugs (Tier 2) and the highest copay for non-preferred brand name drugs (Tier 3).
555-555-0199@example.comThis is a list of brand name and generic prescription drugs developed and maintained by CareFirst BlueCross BlueShield and used by providers and pharmacists when writing and filling prescriptions. Prior Authorization is used to insure the appropriate use of medications that have specific indications, safety concerns, or have a high potential for overuse.
555-555-0199@example.comWhen an FDA-approved generic equivalent (Tier 1) is substituted for a non-preferred brand name drug (Tier 3).
555-555-0199@example.comThose services that include occupational, physical and speech therapy and select oral health care for the treatment of children with certain congenital or genetic birth defects, to enhance the child's ability to function. These services are directed at developing skills that were never present.
555-555-0199@example.comPrograms for members with chronic health conditions. Services range from quarterly mailings to case management with 24-hour access by phone to a support nurse.
555-555-0199@example.comDescribes the use of a service or supply which does not meet the criteria for determining medical necessity.
555-555-0199@example.comA term that describes the use of a service or supply which is provided with the primary intent of improving appearance, not restoring bodily function or correcting deformity resulting from disease, trauma or previous therapeutic intervention.
555-555-0199@example.comHealth insurance coverage extended to the spouse or partner and unmarried children of the primary insured member. Certain age restrictions on the coverage of children may apply.
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ABAllowed Benefit
Actual ChargeAmount a physician or other practitioner charges for a particular medical service or procedure. The actual charge may differ from the allowed charges under insurance programs.
AcupunctureA technique of oriental medicine performed only by licensed health care providers. Fine needles are inserted into the body at specific points to induce anesthesia, relieve pain or to treat other various disorders.
AdjudicationThe process used by health plans to determine the amount of payment for a claim.
AdmissionFormal acceptance as an inpatient by an institution, hospital or health care facility.
AHAAmerican Hospital Association
Allergy TreatmentPhysician directed medical treatment for allergies, which may include testing and the administration of serum through injections.
Allowed BenefitThe dollar amount allowed for services covered, regardless of the provider's actual charge. A provider who participates in a network cannot charge the member more than this amount for any covered service.
AMAAmerican Medical Association
Ambulatory BenefitsBenefits available for health care services received when a covered person is not confined to a hospital bed as an inpatient. Examples include outpatient care, emergency room care, home health care and pre-admission testing.
Ambulatory ServicesA wide range of health care services, including preventive care, acute care, surgery and outpatient care, in a medical care facility. Services do not require an overnight hospital stay.
Ambulatory SurgerySurgery which does not require an inpatient hospital admission for convalescence or recuperation. May also be referred to as one-day, same-day or outpatient surgery.
AMPAutomated Medical Policy
Ancillary ServicesHospital services other than bed, board and nursing care. Examples include drugs, dressings, operating room services, special diets, radiology, laboratory examinations, anesthesia and medications. Ancillary may include inpatient ancillary services, but also commonly includes services provided by ancillary providers in the home or outpatient setting (i.e., free-standing ambulatory surgical facility, radiology, laboratory and/or home health care).
AppealA process used by a patient or provider to request the health plan to reconsider a claim decision.
ASCAdministrative Service Contract or Ambulatory Surgical Center
ASCIIAdministrative Standard Code for Information Interchange
ASOAdministrative Services Only
ASPENAutomated Speech Exchange Network
AssignmentThe provider has agreed to accept Medicare's allowed amount as payment-in-full for the service rendered. The provider may not balance bill for these services. This amount may be reduced by specific coinsurance and deductible amounts to be paid by the member.
Attending PhysicianPhysician primarily responsible for the care of a patient in a health care setting (e.g. during hospitalization).
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Basic CoverageHospital and medical coverage only -- does not include extended medical, major medical, dental and rider coverage. Also includes Medicare Part A and B coverage, exclusive of supplementary coverage.
BBBilling a member for the difference between the allowed charge and the actual charge. See Allowed Benefit.
BCBSABlue Cross and Blue Shield Association
BCBSDEBlue Cross Blue Shield of Delaware
BCIQBlue Cross Inquiry
Behavioral Health Services555-555-0199@example.com
BenefitAny service or supply covered by the member's health insurance plan or contract.
Benefit PeriodA period of time for which covered services (or benefits) are eligible for payment.
Benefits AdministratorIndividual responsible for handling employee health benefits for the employer.
BIDSBenefit Identification System
BlueChoiceAn HMO plan offered by CareFirst BlueChoice, Inc., an independent licensee of the Blue Cross Blue Shield Association.
Brand Name DrugA prescription drug that has been patented and is only available through one manufacturer.
BUCSBlue United Cross and Shield (Credit Union)
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C & SClaims and Service
CAREClaims Adjudication and Review System
CarrierCommercial insurance company, a Blue Cross and Blue Shield plan or a Medicare claims agent.
Carve-out BenefitsCoverage stipulating that Medicare-eligible members of a group receive benefits at least equal to benefits received by non-Medicare group members. Members are reimbursed up to the group's contract limitations, less what Medicare paid or would have paid if the member were Medicare-eligible and Medicare were the primary coverage.
Case ManagementAssignment of health insurance plan staff to help a member manage chronic or severe medical conditions.
ChemotherapyTreatment of malignant disease by chemical or biological antineoplastic agents. High-dose chemotherapy is a type of chemotherapy often used in conjunction with tissue transplants.
Chiropractic CareA therapy administered by a licensed Chiropractor that involves manipulation or adjustment of the spine.
Chronic CareInpatient or outpatient services provided to patients who suffer from a prolonged illness.
ClaimA request for payment for benefits received or services rendered. Either the member or the provider submits claims to the carrier.
CMPColumbia Medical Plan
CMSCenters for Medicare & Medicaid Services
CNMCertified Nurse Midwife
COBContractual provision which reduces the benefits under one contract to the extent that those benefits are available under a second contract.
COBRAFederal legislation that includes a requirement for groups with 20 or more employees to offer extended health insurance coverage at the member's expense to members and eligible dependents who leave the group or are otherwise no longer eligible for the group's coverage.
COCA document describing the benefits, limitations and exclusions of coverage provided by an insurance company.
CoinsuranceThe percentage or amount members are required to pay for covered services. Coinsurance is a percentage of the allowed benefit or cost. For example, if your coinsurance is 20%, and the allowed cost is $100, your coinsurance cost would be $20.
COMPComprehensive Insurance
ContinuationLocal or federal legislation that includes a requirement for groups to offer extended health insurance coverage at the member's expense to members and eligible dependents who leave the group or are otherwise no longer eligible for the group's coverage.
Continuity of CoverageProcedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment.
ContraceptionMethods, drugs or devices for preventing pregnancy.
ContractA legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.
Contract/Certificate HolderGroup or person to whom a contract or certificate is issued.
ConversionChange in a customer's contractual status. For example, transfer from group to direct payment coverage upon termination of employment.
Conversion OptionThe choice to purchase individual coverage by a person who is leaving an employee group.
CopaymentThe dollar amount a member pays when services are received, regardless of the allowed amount. For example, if your copayment is $15 for a visit to your primary care doctor, your cost would always be $15 for those visits. Your insurance plan would pay the remainder of the allowed cost. Also known as copay.
Cost SharingHealth insurance policy provisions that require insured individuals to
Covered PersonPerson, including eligible dependents, entitled to benefits under the
Covered ServicesApplies to services or supplies specified in the contract for which benefits are available under the member's plan.
CPEPContractor Performance Evaluation Program
CPTCurrent Procedural Terminology
CRNACertified Registered Nurse Anesthetist
CRNPCertified Registered Nurse Practitioner
Custodial CareCare which is provided primarily to meet the personal needs of the patient. Custodial Care does not require the continuous attention of skilled medical or paramedical personnel. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care that does not require continuing services of medically trained personnel.
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Day Treatment CenterAn outpatient psychiatric facility or hospital which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.
DeductibleThe dollar amount of covered services based on the allowed benefit that must be paid by an individual or family per benefit period before the insurance company (CareFirst) begins to pay its portion of claims.
DEFRADeficit Reduction Act of 1984
Dental CareRoutine preventive and treatment of teeth and the structures directly supporting the teeth. Generally, dental care is not covered by the health benefit plan.
Dependent(s)A member who is covered as the spouse, eligible child or grandchild of a subscriber (the employee).
DHMHDepartment of Health and Mental Hygiene
DHMODental Health Maintenance Organization
Diagnostic TestsMedically necessary test(s) and/ or non-surgical procedure(s) ordered by a physician/ dentist to determine if the patient has a certain condition or disease. Such diagnostic tools include radiology, laboratory, pathology services or tests.
DMEGoods, implements, prosthetics, etc., that are prescribed for patient
DMODental Maintenance Organization
DPDirect Pay/Direct Processing
DRGDiagnosis Related Group
Drug Formulary555-555-0199@example.com
Duplicate CoverageEnrollment of one person for the same type of benefits under more than one contract.
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EAPEmployee Assistance Program
ECFExtended Care Facility
Effective DateThe date on which health insurance coverage begins.
Elective SurgerySurgery for a condition that is not considered an emergency.
EligibilityInsured person's qualification for coverage as an eligible member under the contract at the time health care is rendered.
Eligibility PeriodPeriod of time before a group member becomes eligible for benefits. This is defined by each group.
Emergency CareCare for patients with severe or life-threatening conditions that require immediate intervention.
Emergency SurgeryProcedure that must be performed in a situation that is serious or life-threatening for the patient.
EnrolleeAn individual who is enrolled and eligible for coverage under a health plan contract. Also known as the "insured."
EnrollmentProcess by which a person completes an enrollment form or application in order to become a member of health insurance coverage under a contract.
EOBA statement a member receives that describes how a claim was processed for benefits, including the member's liability for services rendered.
EOMBExplanation of Medicare Benefits
ERISAEmployee Retirement Income Security Act
ER/EDEmergency Room/Emergency Department
Evidence of Coverage (EOC)A summary detailing the terms, conditions and limitations of your group coverage.
ExclusionSpecific circumstances or services listed in the contract for which benefits will not be provided.
Experimental ProceduresAny service or supply that is in the developmental stage or is in the process of human or animal testing.
Expiration Date555-555-0199@example.com
E&B/EABEnrollment and Billing
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FADFunctional Analysis and Design
Family DeductibleThe amount of annual deductible required to be paid when there are two or more family members on the policy. Many CareFirst BlueCross BlueShield policies limit the annual family deductible to two times the individual deductible.
Family MembershipProvides coverage for a husband, wife, and children or grandchildren, or a single parent with one or more children. Each additional child can be added to the family membership at no extra cost. Eligibility rules for children over 18 vary by plan and area, as do eligibility rules for grandchildren.
FDAFood and Drug Administration
Fee-for-Service Payment SystemA system in which the insurer will either reimburse the group member or pay the provider directly for each covered medical expense after the expense has been incurred.
FEP/FEBHPFederal Employee Program/Federal Employee Benefits Health Plan
FOPField of Practice
FormularyA formulary is a preferred list of drugs. For example, the CareFirst BlueCross BlueShield prescription drug program is based on a formulary. With the CareFirst BlueCross BlueShield Three Tier program, you pay the lowest copay for generic drugs (Tier 1), a higher copay for brand name drugs on the formulary (Tier 2) and the highest copay for brand name drugs not on the formulary (Tier 3).
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Generic DrugA drug which is the pharmaceutical equivalent to one or more brand name drugs. The Food and Drug Administration has approved such generic drugs. They meet the same standards of safety, purity, strength and effectiveness as the brand name drug.
GMIRGroup Master Information Report
GroupThe employer company, organization or association that contracts with your insurance company to provide health benefits to eligible employees and their dependents.
Group AdministratorIndividual responsible for handling employee health benefits for the employer.
Group Contract (GC)A legal agreement between an employer group and a health plan that describes the benefits and limitations of the coverage.
Group Contribution/Employer ContributionPortion of premiums that an employer or other group entity pays toward the cost of its members' and/or dependents' coverage.
Group NumberGroup-specific identification number.
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HCACCHealth Care Access and Cost Commission
HCFAHealth Care Financing Administration (Medicare)
HCPCSHCFA Common Procedure Coding System
Health Benefit PlanThe health insurance product offered by a health insurance company. It is defined by the benefit contract and represents a set of covered services and a provider network.
Hearing ServicesServices related to the hearing structures of the ear.
HIAAHealth Insurance Association of America
HIPAALegislation designed to streamline the health care and insurance industries and to protect the privacy and identity of health care consumers. HIPAA also has provisions designed to help people get or keep health insurance in certain circumstances. For more information, http://www.cms.hhs.gov. Also see HIPAA Eligible or MHIP.
HIPAAHealth Insurance Portability and Accountability Act of 1996
HIPAAProvides for "portability" of insurance coverage when leaving a group
HMOA health benefits program that usually has the lowest out-of-pocket costs. HMOs require that the member select a primary care physician, generally a family practitioner, internist or pediatrician, who is part of the plan's network. There are generally small copayments and no claims to file. In an HMO, a referral is required from the primary care physician to see any specialist in its network except an OB/GYN.
Home Health CareSkilled nursing and related health services provided by home health agencies to patients in a home setting. Services may also include physical therapy, occupational therapy, speech therapy, medical social services, home nursing services and provision of medical supplies and equipment.
Home Infusion TherapyThe administration of intravenous drug treatment in the home.
HospiceProgram or facility that provides medical care and support services for terminally ill patients and their families. The hospice provides services either directly or on a consulting basis with the patient's physician or a community agency.
HospitalAn institution whose primary function is to provide inpatient, diagnostic and therapeutic services. The services are for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.
HSCRCHealth Services Cost Review Commission
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ICDInternational Classification of Diseases
ICMIndividual Case Management
Identification CardDocument issued to a covered member confirming his or her eligibility to claim benefits.
IHMIntegrated Health Management
ImmunizationsVaccines against certain diseases, which can be administered either orally or by injection.
In-NetworkRefers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage members to use participating in-network providers to reduce out-of-pocket expenses.
Incidental ProceduresProcedures carried out at the same time as a primary procedure that are clinically integral to the performance of the primary procedure. A participating provider has contractually agreed to write-off the charges.
Indemnity PlanAlso called a "fee-for-service" plan. Members typically pay a set percentage of the allowed benefit. Typically, members can see anyprovider they choose. The insurance reimburses the member, or pays the provider directly. These plans may involve more paperwork and out-of-pocket expenses for the member.
Indemnity Plans555-555-0199@example.com
InfertilityTerm used to describe the inability to become pregnant after a year or more of regular sexual relations without the use of contraception.
Infusion TherapyTreatment that places therapeutic agents into the vein, including intravenous feeding.
InsuredPerson, including dependents, covered by a contract. Also known as "covered person" or "member."
Investigational Procedures555-555-0199@example.com
IPPerson admitted to the hospital to receive hospital services, including room, board and general nursing care.
IPAA type of organization which contracts with individual providers or groups of providers to arrange for the provision of their professional services to enrollees of a Health Maintenance Organization (HMO).
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JCAHOJoint Commission on Accreditation of Healthcare Organizations
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L / ELeft Employment
LANLocal Area Network
Lifetime MaximumThe maximum amount the plan will pay in benefits for each member during their lifetime.
LimitationSpecific circumstances or services listed in the contract for which benefits will be limited.
LOSLength of Stay
LPNLicensed Practical Nurse
LPTLicensed Physical Therapist
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MACMaximum Allowable Cost/Maximum Annual Copayment
Managed CareA general term for organizing doctors and hospitals into health care delivery networks with the intent of lowering costs and managing the medical care provided. HMOs were the earliest form of managed care. Today there are many different kinds of plans, including Preferred Provider Organization (PPO) plans.
Mandated BenefitsSpecific component of health care coverage required by state or federal government.
Maternity CareThe care and treatment related to pregnancy and delivery of a newborn child.
Maximum Annual CopaymentThe limit on the amount of money a member spends in copayments in a calendar year for covered in-network expenses.
MBMedical Benefits
MCOManaged Care Organization
MCSManaged Care System
MED-CHIMedical & Chirurgical Facility of Maryland
Medical Equipment555-555-0199@example.com
Medical UnderwritingThe process of reviewing each applicant's personal health history and current health status to determine enrollment eligibility.
Medically NecessaryThe term "medically necessary" describes the use of a service or supply which is:
MedicareA national, federally-administered health insurance program covering the cost of hospitalization, medical care, and some related health services for most people over age 65 and certain other eligible individuals.
Medicare Approved ChargeAmount on which Medicare bases its payment for medical services. It is the lower of either Medicare's fee schedule or the doctor's or supplier's actual charge for a service or supply.
Medicare Eligible EmployeesAll eligible employees over 65 that are not TEFRA eligible, as well as
Medicare Supplement ContractHealth insurance plan available to Medicare eligibles to cover the costs of physicians' services and other medical and health services not covered by Medicare.
Medicare (Part A)Part of the Medicare law providing benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment.
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