Glossary

The amount a healthcare provider actually bills a patient. You may have seen the phrase, "The actual charge may be different from the allowable charge." This means BCBSKS may only cover a portion of what a doctor charges a member. For example, a doctor bills $40 for an office visit. This is the actual charge. But BCBSKS may only allow $35 for an office visit. This is the allowable charge.

Group that contracts with BCBSKS to provide administrative and claims payment services according to the group's coverage criteria. The group assumes the risk for the cost of services the subscribers receive, rather than paying premiums. The group can also purchase stop-loss insurance from BCBSKS that limits such risk.

The State of Kansas department in Social and Rehabilitation Services that is responsible for the certification of Outpatient Substance Abuse Facilities.

The maximum amount BCBSKS will pay for a covered service. You may have seen the phrase, "The actual charge may be different from the allowable charge." This means BCBSKS may only cover a portion of what a doctor charges a member. For example, a doctor bills $40 for an office visit. This is the actual charge. But BCBSKS may only allow $35 for an office visit. This is the allowable charge.

Maximum amount on which payment is based for covered healthcare services. This may be called "eligible expense," "payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.

The anniversary of when the coverage was effective.

The 12-month period based on the group anniversary month.

A request for your health insurer or plan to review a decision or grievance again.

A method of payment where the insurance premium is deducted directly from an account at a financial institution on a monthly basis.

When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Services and supplies a health plan pays for. The term also refers to the amount a health plan allows.

Document that explains the benefits for self-funded (ASO) group subscribers. This is not the same as a Summary Plan Description (SPD) or a Plan Document.

The period of time a health plan will pay for covered benefits. Benefit periods are usually one year. They don't always reflect a calendar year.

A teleprocessing system that allows any Blue Cross and Blue Shield Plan to make available to other Blue Cross and Blue Shield Plans (in-or out -of-state) the same discounts they have negotiated with providers for their own customers.

A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.

The period between Jan. 1 and Dec. 31 of any given year.

The reimbursement agreement between BCBSKS and providers of healthcare services for traditional benefit programs. Providers are paid predetermined maximum allowances for covered healthcare services and agree to file claims on behalf of members.

A company that signs a contract with the federal government to handle Medicare claims from healthcare providers.

Coordination of services to help meet a patient's healthcare needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Document describing the benefits included within an insured Group Contract which is issued to each Primary Member. This is not the same as a Summary Plan Description (SPD) or a Plan Document.

Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

The geographical area covered by a network of healthcare providers. BCBSKS covers the state of Kansas, excluding Johnson and Wyandotte counties.

Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother and fetus. Morning sickness and a non-emergency caesarean section aren't complications of pregnancy.

Non-public information that includes strategic and/or competitively sensitive information including, but not limited to, BCBSKS, the Blue Cross Blue Shield Association, or other BCBS company trade secrets, policies, procedures, data and processes.

A federal statute that requires most employers (those groups with more than 20 employees) to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).

Employers who offer a group health plan for their employees and have fewer than 20 employees on the payroll are affected by the provisions of the 1984 Kansas Senate Bill 704. This law governs group health insurance benefits for hospital/medical/surgical services. If employees and/or dependents have been covered by group health insurance coverage for 90 days prior to termination, Blue Cross and Blue Shield of Kansas must make available, to the individual(s) affected, the same group hospital/medical/surgical coverage they had prior to termination. This continuation of coverage must be offered at the same premium available through the group for a period of six months. Individuals choosing this option will be billed directly by Blue Cross and Blue Shield of Kansas - not through the group. This law affects all groups except those on self-insurance. If the group health insurance is replaced by a similar group coverage within 31 days, the employee is not eligible for continued group benefits under State continuation and conversion laws. If the employee and/or dependents have not been covered by your group health insurance for 90 days prior to termination, we will automatically offer them our Non-Group Conversion program in lieu of the continuation rights.

A period of 12 months, starting the first day of a given month.

Any licensed provider of healthcare services who has signed an agreement to accept the BCBSKS allowance as payment-in-full for covered services. Types of contracting providers include (but are not limited to) hospitals, medical care facilities, pharmacies, ambulatory surgical centers, doctors, other licensed or certified practitioners (as described in the contract) and providers of ambulance services.

A fixed amount (for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered healthcare service.

Strategies used to limit or control healthcare costs that do not sacrifice the quality of care.

A method of dividing the cost of healthcare among consumers, insurance companies, employers and providers. For example, an employer may pay part of the premiums for insurance. BCBSKS will pay part of the healthcare bills, and the member will pay part. If a doctor is part of our network, then he or she will cover part of the cost by negotiating a discount for his or her services. Everyone shares in the expenses to keep costs down.

Specific services the health plan will provide benefits for.

The amount you owe for covered healthcare services before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

A person eligible for coverage under a benefits plan because of that person's relationship to the primary member. Spouses and children are often eligible for dependent coverage.

A non-group member who pays his or her insurance premium directly to BCBSKS.

Identifying a patient's healthcare needs after discharge from inpatient care.

Voluntary programs which give members the information and support needed to live well with chronic conditions. These programs help members understand their doctors' instructions and improve the way they care for themselves every day.

Voluntarily terminating one's participation in a health benefits plan.

This provision applies to covered group employees (or family members of the employee) who are eligible for benefits from another group healthcare plan. Duplication of benefits coordination is conducted to make sure members do not profit by receiving payment from more than one source.

Equipment and supplies ordered by a health provider for every day or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Ambulance services for an emergency medical condition.

Emergency services you get in an emergency room.

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Federal legislation that establishes certain rights and protections to participants of most employer welfare (e.g., health, dental, life) and pension (e.g., 401(k), retirement) benefit plans.

Healthcare services that your health insurance or plan doesn't pay for or cover.

A summary sent to the member showing how much BCBSKS paid, what the member's financial responsibility may be, and any provider write-offs.

See Medicare Summary Notice.