Glossary of Health Insurance Terms

A patient contract addendum that provides benefits in addition to those in the basic contract.

Midwest Association of Medical Equipment Suppliers.

A patient contract that employs the primary care physician -PCP concept. The PCP has the responsibility of directing the patient's course of treatment, which includes the possible referrals to other health care specialists. The primary goal is to deliver cost-effective healthcare without sacrificing quality or access. Blue Select is a BCBSKS managed care product.

Coverage for healthcare services that insurers are required by state or federal law to provide for patients.

The skillful treatment of subluxations through certain chiropractic and osteopathic methods.

See "Maximum Allowable Payment."

The department at BCBSKS that sells health insurance and is responsible for the relationship between employer groups and non-groups members/members. BCBSKS also has a subsidiary company called Advance Insurance Company that sells life, accident, death and dismemberment and disability products.

The BCBSKS employee who sells to and provides a liaison for the employer groups and non-group members/members and BCBSKS.

Means the amounts established by BCBSKS as the highest amount reimbursed for services which are covered under the terms of the patient's contract. Our Board of Directors reviews these allowances each year for increases for the next calendar year. We may make adjustments to individual MAPs throughout the year if it is determined to be insufficient for a given service. Providers no longer establish customaries and prevailings, nor register charges with us as before BCBSKS implemented CAP -with MAP reimbursement on Jan. 1, 1984.

Medical Doctor.

Title XIX of the Social Security Act Amendment of 1965 which provides state and federally funded coverage for those who meet certain requirements based on their financial status. Sometimes referred to as welfare or Title XIX.

The entity that contracts with the state government to process Medicaid claims.

The position at BCBSKS that oversees the day-to-day activities of medical and utilization review for BCBSKS claims.

See "Emergency medical care."

The patient's contract describes medically necessary services as those that:

• Are performed or prescribed by a doctor.
• Are consistent with the diagnosis and treatment of a patient's condition.
• Are in accordance with standards of good medical practice.
• Are not for the convenience of the patient, his/her family or the provider.
• Are provided in the most appropriate setting.

The office documents that support:

• Charging practices.
• Accounts receivable.
• Type of service performed.
• That the service was actually performed.
• Medical necessity of the service.

These records would include but not be limited to:

• Appointment books.
• Ledgers.
• Invoices.
• Exam findings.
• Daily progress notes.
• Histories and physicals.
• Lab and x-ray reports.
• Consultation reports.

A contracting provider agrees to make this information available to BCBSKS at no charge. Accepted methods of documentation for daily medical records include Subjective, Objective, Assessment and Plan – SOAP Notes and History, Exam, Assessment and Layout – HEAL.

The department at BCBSKS that oversees the application of medical necessity policies and utilization guidelines for BCBSKS.

Coverage chosen by some groups for employees age 65 or older or disabled to provide benefits which, combined with Medicare benefits, will bring the over-all level of benefits up to the same level of benefits provided for those in their group under 65 or not disabled.

Title XVIII of the Social Security Act Amendment of 1965 which provides federal coverage for hospital inpatient, skilled nursing facility and home health care agency services for persons age 65 or older or those disabled.

The entity that contracts with the federal government to process the Medicare Part A claims.

Title XVIII of the Social Security Act Amendment of 1965 which provides federally funded coverage for outpatient hospital, home, and office care for persons age 65 or older or those disabled.

The entity that contracts with the federal government to process Medicare Part B claims.

A patient contract that provides benefits complementary to Medicare. Usually these contracts pay the deductibles and coinsurance amounts on Medicare-covered services only. Some supplemental contracts pay less than this and some may pay more.

A program that offers Medicare beneficiaries a wider variety of health plan options than previously, including preferred provider organizations and provider sponsored organizations. BCBSKS does not participate in this program.

Insurance that supplements the money paid by Medicare. This insurance usually pays the difference between what the provider charges and what Medicare allows for a given service. Plan 65 F contract is a form of this type of insurance.

Anyone who lives in the same dwelling who was claimed as a tax deduction during the year for which benefits were contracted.

Any person entitled to receive medical, surgical and ancillary services pursuant to the terms of HMO or managed care patient contract.

See "Medicare Exclusion Rider."

The two-digit alpha and/or numeric suffix that immediately follows the procedure code on the claim form. This suffix gives BCBSKS additional information about the service provided such as right eye, left eye, provider is requesting individual consideration, service performed was less than normal, etc.

See "Medical Review."

Magnetic resonance imaging.

Manipulation under anesthesia.

See "Units of Service."

The factor by which some procedure codes' MAPs may be determined when used in conjunction with the Kansas adjusted RVU for the procedure code.