Glossary of Health Insurance Terms

Average Allowed Charge Per Patient Per Year. See "Kansas Chiropractic Network"

See "Accidental Injury".

Day, month and year injury or accident occurred.

Injury to the body caused solely through external, violent and accidental means. This definition has been liberalized to include sprains and strains.

Duties performed as part of a patient's daily routine of self-care, such as bathing, dressing and eating.

The provider's net payment made to purchase an item, after taking into account purchasing allowances, discounts and rebates.

BCBSKS staff member who decides insurance policy rates as well as conducts various other statistical studies.

Treatment for a short-term or episodic illness or health problem.

Treatment for a short-term or episodic illness or health problem.

Americans With Disabilities Act.

See "Alcohol and Drug Abuse Services".

Processing a claim through a series of edits to determine the proper payment.

See "Activities of Daily Living".

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.

Our subsidiary that sells complete packages of life and disability insurance benefits. The agency representatives are licensed to sell life, accidental, death and dismemberment, and disability insurance. This agency operates completely separate from BCBSKS. The chief operating officer of this agency is a member of BCBSKS Steering Committee.

See "Contracting Provider Agreement".

American Hospital Association.

Medical care givers who are not in independent practice and are usually under the supervision of a licensed/certified healthcare professional such as a physician, optometrist, chiropractic physician, dentist, etc.

The lesser amount of the actual charge or the maximum allowable payment -MAP, or the patient contract indemnified payment limitation amount.

All forms of providing health insurance coverage other than the traditional fee for service type of contract.

Healthcare services outside the traditional medical practice, this type of care can include such therapies as: acupuncture, holistic medicine, homeopathy, non-medical massage therapy, herbal therapy, hypnosis, naturopathy, and biofeedback.

See "Current Procedural Terminology".

A facility where operative procedures are performed and the patient is released the same day.

Healthcare such as lab and x-rays.

The anniversary of when the coverage was effective.

American Optometric Association.

American Orthotic and Prosthetic Association.

This is the procedure by which a patient or a provider can have a service reconsidered that has been denied before the service is rendered.

The process by which a contracting provider may have a claim adjudication or a medical necessity denial reconsidered.

See "Ambulatory Surgery Center".

American Speech and Hearing Association.

See "Administrative Services Only".

The procedure by which a patient may have the reimbursement sent to a provider if the provider is one of the types to whom we do not offer contracts, such as opticians, hearing aid dispensers, registered nurses and licensed practical nurses.

If we offer a contract to a particular provider type and a specific provider within that type chooses not to contract, the reimbursement cannot be sent to the provider even if the patient wants it to be. See "Non-contracting provider".

Term used to designate financial liability in compensation/reimbursement arrangements. A provider may be "at risk" for additional costs, for example, if the expense of caring for a particular panel of patients exceeds the provider's capitation payment.

Term used to designate financial liability in compensation/reimbursement arrangements. A provider may be "at risk" for additional costs, for example, if the expense of caring for a particular panel of patients exceeds the provider's capitation payment.

The usual cost of pharmaceuticals charged to a pharmacy provider by a large group of pharmaceutical wholesale suppliers.

See "Average Wholesale Price".

See "Blue Cross Blue Shield Association."

See "Blue Cross and Blue Shield of Kansas City."

See "Blue Cross and Blue Shield of Kansas, Inc."

The extent or degree of service a patient is entitled to receive based on their health insurance contract.

Healthcare services offered under the terms of a health insurance policy.

The designated time period during which, covered medical services are reimbursable by BCBSKS. This can be a calendar year or a contract -anniversary year as determined by the effective date of the patient's contract.

Specific kinds of medical services that are grouped together under provisions of the patient's contract. Examples would be: lab and x-ray; outpatient psychiatric; prescription drugs.

The dollar amount available for the cost of covered medical services.

A health maintenance organization, developed by BCBSKC, which provides a comprehensive set of health maintenance and treatment services for enrolled members. This product is no longer being sold in our jurisdiction -BCBSKS service area, effective 1-1-99.

A type of health insurance coverage that BCBSKS sells. This coverage has open access to all CAP contracting providers, meaning referrals from a PCP are not required. This coverage is considered a PPO type of contract.

An entity that provides health insurance coverage in the Kansas City, Missouri metropolitan area including Johnson and Wyandotte counties in Kansas. BCBSKC operates independently of other BCBS Plans.

An entity that provides health insurance coverage in Kansas excluding Johnson and Wyandotte counties. The home office is in Topeka. Referred to in this manual as BCBSKS. BCBSKS operates independently of other BCBS Plans.

The national organization of Blue Cross and Blue Shield Plans in the United States, territories and Western Europe. The association is headquartered in Chicago, Illinois, and coordinates the efforts of the Plans at a national level.