Glossary of Health Insurance Terms

See "Evaluation and Management Procedure Codes."

See "Electronic Data Interchange."

The day that a patient or provider contract begins. Rules, regulations and guidelines for claims processing can also have effective dates.

See "Employer Identification Number."

The exchange of health care information, in the case of BCBKS this is claims information, between two entities, via computer technology.

The paperless submission of claims via computer tape or telephone wires. For more information call BCBSKS Electronic Media Services at 1-800-472-6481 or 785-291-7153.

See "Emergency Medical Care."

A sudden unexpected onset of a health condition that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect requirement of immediate medical attention, where failure to provide would result in serious impairment to functions of a body organ or part, or would place the patient's health in serious jeopardy.

Ambulance companies. Can also refer to care given to a patient in an extremely urgent situation.

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.

Federal Tax Number that is used to generate Federal 1099 forms to IRS.

See "Electronic Media Services" or "Emergency Medical Services."

The geographic location of a managed care program -i.e. Blue Select, to which a member/member -patient belongs.

See "Explanation of Benefits."

See "Explanation of Medicare Benefits."

A specified time frame that includes all care administered for a given disease.

See "Exclusive Provider Organization."

See "Employee Retirement Income Security Act of 1974."

The codes for office calls, consultants, nursing home visits and inpatient hospital calls in the AMA CPT book. These codes are based on the complexity of 1 the patient's condition, and 2 the provider's decision-making process. These are referred to as E and M codes.

See "Contract Exclusion."

This is a form of a PPO which requires the patient to seek care from a panel provider.

A service, piece of equipment, facility or supply -including drugs or drug usage that has not been proven effective to the point that it has been accepted as standard medical practice by the general medical community, and/or does not have federal approval. BCBSKS considers these provider write-offs unless a waiver is signed prior to the service being rendered.

The computer-generated explanation of benefits that is mailed to a patient when BCBSKS processes claims. If the provider is contracting they receive a RA giving the same information. This explanation indicates how much was paid, what the patient's responsibility is and what the provider write-off amount is.

The summary sheet that outlines how Medicare processed services submitted to them on behalf of their beneficiaries.

A computer generated document for a BCBSKS Plan 65 or MER claim, where Medicare was primary.