To find the definition of a term, click on the corresponding first letter of the term below.
The abdominal aorta is part of the main blood vessel that carries blood from the heart to the body. It carries blood from the chest to the abdomen, pelvis, and legs.
An objectively demonstrable impairment of bodily function or damage to part of the body caused by trauma from a sudden, unforeseen outside force or object, occurring at an identifiable time and place, and without a person's foresight or expectation.
Insurance professionals who perform the mathematical analysis necessary for setting insurance premium rates.
Acute describes an illness or disease that comes on quickly and usually heals quickly. Pneumonia is an example of an acute illness. An acute illness can become a chronic illness (see chronic).
Inpatient treatment in a hospital or other facility provider for medical and/or surgical conditions that require sustained medical intervention by a physician and skilled nursing care to safeguard a patient's life and health. The immediate medical goal of acute care is to stabilize the patient's condition, rather than upgrade or restore his or her abilities.
A behavioral or physical disorder manifested by repeated excessive consumption of alcohol to the extent that it interferes with a person's health or social or economic functioning.
An arteriogram is a test that uses x-rays and a dye, called a contrast dye, to look at the inside of arteries. Also called an angiography.
Bacteria are living organisms that have just one cell. Some bacteria are infectious. They get into the body and cause diseases, like TB (tuberculosis) and pneumonia. Unlike viruses, bacteria can usually be treated with antibiotics.
Behavioral health is the branch of health care that treats problems with feelings and behaviors, including mental health, addiction, and relationship problems.
A behavioral health specialist is a person who is trained and licensed to help people with behavioral health issues, such as problems with mental health, relationships, or addiction. Behavioral health specialists complete clinical training before they are licensed to practice.
The specified period of time in which an Insured's benefits for incurred Covered Services accumulate toward annual benefit limits, Deductible amounts and Out-of-pocket Limits.
The bile ducts are small tubes that carry bile, a digestive fluid, from the gallbladder (see below) to the small intestines. Bile is made by the liver and stored in the gallbladder. It helps digest fat.
A program that enables Blue Cross of Idaho to process claims for most covered services received by insureds outside of Blue Cross of Idaho's service area while capturing the local Blue Cross and/or Blue Shield Plan's provider discounts.
A name, number, term, sign, symbol, design, or combination of these elements that an organization uses to identify one or more products.
A salesperson who has obtained a state license to sell and service contracts of multiple health plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the health plan or insurer.
The carotid arteries are the major blood vessels that go up the sides of the neck and carry blood to the brain. A partly or totally blocked carotid artery can cause a stroke.
Specialty health service that an insurer or managed care plan obtains for its members by contracting with a company that specializes in that service. See also Carve-Out Companies.
Organizations that have specialized provider networks and are paid on a capitation or other basis for a specific service, such as mental health, chiropractic, and dental. See also Carve-Out.
A process of identifying plan members with special health care needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum health care outcome in an efficient and cost-effective manner.
The license issued by a state to an insurance company, which allows it to conduct business in that state.
An individual registered as a certified registered nurse anesthetist by the state where the service was rendered and performing within the scope of registration.
(with Private Practice Endorsement) - An individual licensed by the state where the service was rendered to provide diagnosis and treatment of mental or nervous conditions and performing within the scope of license.
Cervical describes something that is part of or related to the cervix (see below). Cervical cancer is cancer in the cervix.
A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.
Services rendered, referred or prescribed by a chiropractic physician when practicing within the scope of license.
An individual licensed to practice chiropractic care by the state where the service was rendered.
Chronic describes an illness or disease that lasts a long time and usually does not go away. Diabetes and arthritis are examples of chronic diseases.
An itemized statement of health care services and their costs provided by a hospital, physician's office, or other facility or professional provider.
An application for payment of benefits under a health plan.
A federal act which forbids certain actions believed to lead to monopolies, including (1) charging different prices to different purchasers of the same product without justifying the price difference, and (2) giving a distributor the right to sell a product only if the distributor agrees not to sell competitors' products. The Clayton Act applies to insurance companies only to the extent that state laws do not regulate such activities. See also Antitrust Laws.
An individual licensed to practice clinical psychology by the state where the service was rendered.
The percentage of the maximum allowance or the actual charge, whichever is less, an insured is responsible to pay out-of-pocket for covered services after satisfaction of any applicable deductibles or copayments, or both.
Group: The greatest aggregate amount payable by Blue Cross of Idaho on behalf of an Insured for all Covered Services covered under any agreement, certificate, contract or policy issued by Blue Cross of Idaho during all periods in which the Insured has been continuously enrolled with the Group.. The Comprehensive Lifetime Benefit Limit excludes all benefits paid while an Insured was enrolled or covered under a Short Term Blue Policy or its successor and/or any Basic, Standard, or Catastrophic Benefit Plan mandated by the state. Payments applied toward specific Lifetime Benefit Limits also apply toward the all-inclusive Comprehensive Lifetime Benefit Limit.
Individual: The greatest aggregate amount payable by Blue Cross of Idaho on behalf of an Insured for all Covered Services during all periods in which the Insured has been continuously enrolled in one (1) or more individual policies issued by Blue Cross of Idaho. The Comprehensive Lifetime Benefit Limit excludes all benefits paid while an Insured was enrolled or covered under a Short Term Blue Policy or its successor and/or any Basic, Standard, Catastrophic, or HSA compatible Benefit Plan mandated by the state. Payments applied toward specific Lifetime Benefit Limits also apply toward the all-inclusive Comprehensive Lifetime Benefit Limit.
A condition existing at or from birth, which is a significant deviation from the common form or function of the body, whether caused by a hereditary or a developmental defect or Disease. In this Policy, the term significant deviation is defined to be a deviation which impairs the function of the body and includes but is not limited to the conditions of cleft lip, cleft palate, webbed fingers or toes, sixth toes or fingers, or defects of metabolism and other conditions that are medically diagnosed to be Congenital Anomalies.
A federal act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment.
Hospice nursing care provided during periods of crisis in order to maintain a terminally ill insured at home. A period of crisis is one in which the insured’s symptom management demands predominantly skilled nursing care services.
A Provider that has entered into a written agreement with Blue Cross of Idaho regarding payment for Covered Services rendered to an Insured under a Preferred Blue PPO program.
A designated dollar and/or percentage amount separate from coinsurance that an insured is financially responsible for and must pay to a provider at the time certain covered services are rendered or provided.
A provider from whom an insured must receive covered services in order to receive benefits.
A service, supply or procedure specified under an insured's policy for which benefits will be provided to an insured when rendered by a covered provider.
The process of obtaining, reviewing, and verifying a provider's credentials -- the documentation related to licenses, certifications, training and other qualifications -- for the purpose of determining whether the provider meets the insurer's or managed care organization's pre-established criteria for participation in the network.
Care designed principally to assist a person in engaging in the activities of daily living; or services which constitute personal care, such as help in walking and getting in and out of bed; assistance in bathing, dressing, eating and using the toilet; preparation of special diets, and supervision of medication, which can usually be self-administered and which does not entail or require the continuous attention of trained medical or other paramedical personnel. Custodial care is normally, but not necessarily, provided in a nursing home, convalescent home, rest home or similar institution.
A cystoscope is a thin tube with a light. It is used to examine the insides of the bladder and the urethra. Small tools can be inserted through the tube to remove tissue samples or bladder stones.
The amount an insured is responsible to pay out-of-pocket before an insurer begins to pay benefits for covered services. The amount credited to the deductible is based on the maximum allowance or the actual charge, whichever is less.
An individual licensed to practice dentistry by the state where the service was rendered.
The treatment of teeth and supporting structures, including but not limited to, replacement of teeth.
A test or procedure performed on the order of a physician or other professional provider because of specific symptoms, in order to identify a particular condition, disease, illness or accidental injury. Diagnostic services include, but are not limited to: (1) radiology services, (2) laboratory and pathology services, and (3) cardiographic, encephalographic and radioisotope tests.
The digestive organs help the body breakdown and absorb food. They include the stomach, liver, gallbladder, pancreas, and intestines. They are part of the digestive system, which also includes the mouth, throat, esophagus, rectum, and anus.
Diphtheria is an infection of the nose and throat. Common symptoms include a severe cough, fever, chills, and trouble breathing. The infection can block the airways. The diphtheria bacteria produces toxins that spread through the bloodstream and damage other organs., such as the heart. The vaccines Dtap, TdaP, DT, and Td prevent diphtheria.
Any alteration in the body or any of its organs or parts that interrupts or disturbs the performance of vital functions, thereby causing or threatening pain, weakness or dysfunction. A disease can exist with or without a person's awareness of it, and can be of known or unknown cause.
A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.
A discectomy is surgery to remove a disc (see above) in the spine that is pressing on the spinal cord or other nerves and causing pain.
A doppler ultrasound uses sound waves to see how well blood flows through a blood vessel. It can show if a major artery has a narrow part that is blocking the flow of blood.
A review program that evaluates whether drugs are being used safely, effectively, and appropriately.
Items which can withstand repeated use, are primarily used to serve a therapeutic purpose, are generally not useful to a person in the absence of accidental injury, disease or illness and are appropriate for use in the patient's home.
A business that sells or rents durable medical equipment.
EEG stands for electroencephalogram. An EEG is a brain wave test to detect problems in how the brain cells communicate. Electrodes are placed on the scalp and connected to a recording machine, which translates the electrical activity of the brain into patterns on a computer screen.
The date when coverage for an insured begins under a policy.
The application-to-application interchange of business data between organizations using a standard data format.
A person eligible for enrollment under an enrollee's coverage as specified in the Eligibility and Enrollment section of a specified policy.
A person entitled to apply to be an enrollee as specified in the Eligibility and Enrollment section of a specified policy.
An evaluation conducted by an insurer to determine the medical necessity of an insured's emergency inpatient admission or unscheduled maternity admission, and the attendant course of treatment.
An inpatient admission to a hospital or other inpatient facility due to the sudden, acute onset of a medical condition or an accidental injury which requires immediate inpatient medical treatment to preserve life or prevent severe, irreparable harm to a patient.
A medical condition in which sudden and unexpected symptoms are sufficiently severe to necessitate immediate medical care. Emergency medical conditions may include, but are not limited to, heart attacks, cerebrovascular accidents, poisonings, loss of consciousness or respiration, and convulsions.
A mental health counseling program provided to employees and designed to identify an individual's or family's problem(s) and provide the short-term counseling necessary to achieve resolution of his/her/their identified problem(s).
A broad-reaching law that establishes the rights of pension plan participants, standards for the investment of pension plan assets, and requirements for the disclosure of plan provisions and funding.
The endometrium is the lining of the uterus (womb). It thickens between menstrual periods and is shed when a woman has her period.
An eligible person who has satisfied an insurer's eligibility requirements and has enrolled for coverage.
The date of enrollment of an individual under a policy or, if earlier, the first day of the probationary period for such enrollment.
The enrollment of an enrollee and two or more eligible dependents under a policy.
A federal act which established the Federal Trade Commission (FTC) and gave the FTC power to work with the Department of Justice to enforce the Clayton Act. The primary function of the FTC is to regulate unfair competition and deceptive business practices, which are presented broadly in the Act. As a result, the FTC also pursues violators of the Sherman Antitrust Act.
A system in which the insurer will either reimburse the insured or pay the provider directly for each covered medical expense after the expense has been incurred.
A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given population and that are to be used by an insurer's providers in prescribing medications.
A facility provider that is primarily engaged in providing dialysis treatment, maintenance or training to patients on an outpatient or home care basis.
Unbranded pharmaceutical drugs that meet the same standards for safety, purity, strength, and quality as brand name drugs but typically provide substantial dollar savings versus branded counterparts. AB rated generic drugs are chemically and therapeutically equivalent to corresponding brand name drugs.
The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary.
A gland is an organ that makes a substance that is used by another organ or organs in the body. Glands in the human body produce hormones (see below), digestive fluids, saliva, sweat, and milk.
A graft is a piece of real or artificial bone that is used to repair a broken or injured bone, or to fuse a joint so it cannot move. The graft may be real bone from another place in your own body or from a bone bank, or it may be an artificial bone.
A sole proprietorship, partnership, association, corporation or other entity that has made application for group coverage and has agreed to comply with all the terms and requirements of a specified policy.
An insurance policy provision under which all eligible persons who apply for insurance coverage and who meet certain conditions are automatically issued an insurance policy.
Any hospital or medical policy or certificate, any subscriber policy provided by a hospital or professional service corporation, or managed care organization subscriber policy. Health benefit plan does not include policies or certificates of insurance for specific disease, hospital confinement indemnity, accident-only, credit, dental, vision, Medicare supplement, long-term care or disability income insurance, student health benefits-only coverage issued as a supplement to liability insurance, Workers' Compensation or similar insurance, automobile medical payment insurance, or nonrenewable short-term coverage issued for a period of twelve (12) months or less.
Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the U.S. health care system.
A health care system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, often in return for a fixed, prepaid fee.
Hepatitis is inflammation of the liver. It can be caused by a viral infection such as hepatitis A, hepatitis B, and hepatitis C. It can also be caused by drinking too much alcohol and by taking too much of some medicines.
A contract clause which prohibits providers from seeking compensation from patients for charges which exceed the insurer's maximum allowance for a covered service, excluding deductibles, coinsurance, and copayments.
Any agency or organization that is duly licensed by the appropriate licensing authority to provide skilled nursing care services and other therapeutic services in the state or locality in which it operates.
An individual employed by a contracting hospice, under the direct supervision of a licensed registered nurse (R.N.), who performs, and trains others to perform, intermittent custodial care services which include, but are not limited to, assistance in bathing, checking vital signs, and changing dressings.
A Medicare Certified and licensed, where required, pharmacy or other entity that is principally engaged in providing services, medical supplies, and equipment for certain home infusion Therapy Covered Services, to Insureds in their homes or other locations outside of a Licensed General Hospital.
A hormone is a chemical that travels in the bloodstream and directs cells and organs. The body has thousands of hormones. They control things like sexual development, physical growth, mood, digestion, and reproduction.
A public agency or private organization designated specifically to provide services for care and management of terminally ill patients, primarily in the home.
Skilled nursing care services and home health aide services provided as a part of a hospice plan of treatment.
A written plan of care established and periodically reviewed by the attending physician that describes the services and supplies for the medically necessary palliative care and treatment to be provided to a patient by a hospice.
Hospice therapy services include: (1) hospice physical therapy - the treatment by physical means, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles, and devices to relieve pain, to enable a patient to maintain basic functional skills and to manage symptoms; (2) respiration therapy, and (3) speech therapy.
A hysteroscope is a long, thin instrument with a light at the tip. It is inserted through the vagina and cervix into the uterus (womb). It allows the doctor to view the lining of the uterus. It can also be used to remove parts of the lining.
A hysteroscopy is a procedure that lets a doctor examine and treat the lining of the uterus without making a cut in the belly. A long, thin instrument with a light at the tip, called a hysteroscope (see above), is inserted through the vagina and cervix into the uterus.
A deviation from the healthy and normal condition of any bodily function or tissue. An illness can exist with or without a person's awareness of it, and can be of known or unknown cause.
Agents that represent the products of several health plans or insurers.
Covered services provided by a contracting provider.
A patient who is admitted as a bed patient in a hospital or other facility provider and for whom a room and board charge is made.
Inpatient care is care that includes an overnight stay in a hospital.
An enrollee or an enrolled eligible dependent.
Any technology (service, supply, procedure, treatment, drug, device, facility, equipment or biological product), which is in a developmental stage or has not been proven to improve health outcomes such as length of life, quality of life, and functional ability. A technology is considered investigational if, as determined by Blue Cross of Idaho, it fails to meet any one of the following criteria:
If a technology is determined to be investigational, all services specifically associated with the technology, including but not limited to associated procedures, treatments, supplies, devices, equipment, facilities or drugs will also be considered investigational.
In determining whether a technology is investigational, Blue Cross of Idaho considers the following source documents: Blue Cross Blue Shield Association Technology Evaluation Center (TEC) assessments, the Blue Cross and Blue Shield Association Medical Policy Reference Manual as adopted by Blue Cross of Idaho, and Blue Cross of Idaho Medical Policies. Blue Cross of Idaho also considers, at its discretion, current published medical literature and peer review publications based upon scientific evidence, and evidence-based guidelines developed by national organizations and recognized authorities.
The kidneys are two bean-shaped organs found in the middle of the back on each side of the spine. The kidneys clean (filter) waste from the blood and produce urine. They also control fluid levels in the body.
A laminectomy is surgery to remove a small piece of bone, called a lamina, from the spine.
Any person, firm, corporation, partnership or association that is actively engaged in business that, on at least fifty percent (50%) of its working days during the preceding calendar year, employed no less than fifty-one (51) eligible employees, the majority of whom were employed within a given state. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of state taxation, are considered one (1) employer.
A lesion is a change in some of the cells of an organ or tissue. Some lesions are growths, such as polyps in the colon. Some are flat and can be harder to find.
A short term, acute care, general hospital that: (1) is an institution duly licensed in and by the state in which it is located and is lawfully entitled to operate as a general, acute care hospital; (2) for compensation from or on behalf of its patients, is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of injured and sick persons by or under the supervision of physicians; (3) has organized, functioning departments of medicine and surgery; (4) provides 24-hour nursing service by or under the supervision of licensed registered nurses; and (5) is not predominantly a skilled nursing facility, nursing home, custodial care home, health resort, spa or sanatorium, place for rest, place for the aged, place for the treatment or rehabilitative care of mental or nervous conditions, place for the treatment or rehabilitative care of alcoholism or substance abuse or addiction, place for hospice care, residential treatment facility, or transitional living center.
An individual licensed to practice pharmacy by the state where the service was rendered.
(with Private Practice Endorsement) - An individual licensed by the state where the service was rendered to provide diagnosis and treatment of mental or nervous conditions and performing within the scope of license.
Group: The greatest aggregate amount payable by Blue Cross of Idaho on behalf of an Insured for specified Covered Services covered under any agreement, certificate, contract or policy issued by Blue Cross of Idaho during all periods in which the Insured has been continuously enrolled with the Group. The Lifetime Benefit Limit excludes any relevant benefits paid while an Insured was enrolled or covered under a Short Term Blue Policy or its successor and/or any Basic, Standard, or Catastrophic Benefit Plan mandated by the state. Payments applied toward specific Lifetime Benefit Limits also apply toward the all-inclusive Comprehensive Benefit Limit.
Individual: The greatest aggregate amount payable by Blue Cross of Idaho on behalf of an Insured for specified Covered Services during all periods in which the Insured has been continuously enrolled in one (1) or more individual policies issued by Blue Cross of Idaho. The Lifetime Benefit Limit excludes any relevant benefits paid while an Insured was enrolled or covered under a Short Term Blue Policy or its successor and/or any Basic, Standard, Catastrophic, or HSA compatible Benefit Plan mandated by the state. Payments applied toward specific Lifetime Benefit Limits also apply toward the all-inclusive Comprehensive Benefit Limit
The liver is an organ in the abdomen. It filters blood as it leaves the stomach and the intestines. It makes bile, a digestive fluid. It also helps take toxic chemicals out of the body, and helps the body use some drugs.
The integration of both the financing and delivery of health care within a system that seeks to manage the quality, accessibility, and cost of that care.
Any entity that utilizes certain concepts or techniques to manage the quality, accessibility, and cost of health care. Also known as a managed care plan.
Maximum Allowance is the lesser of the billed charge or the amount established by Blue Cross of Idaho as the highest level of compensation for a Covered Service. If the Covered Services are rendered outside the state of Idaho by a Noncontracting or Contracting Provider with a Blue Cross and/or Blue Shield affiliate in the location of the Covered Services, the Maximum Allowance is the lesser of the billed charge or the amount established by the affiliate as compensation.
The Maximum Allowance is determined using many factors, including pre-negotiated payment amounts; diagnostic related groupings (DRGs); a resource based relative value scale (RBRVS); ambulatory payment classifications (APCs); the Provider’s charge(s); the charge(s) of Providers with similar training and experience within a particular geographic area; Medicare reimbursement amounts; and/or the cost of rendering the Covered Service. Moreover, Maximum Allowance may differ depending on whether the Provider is Contracting or Noncontracting.
In addition, Maximum Allowance for Covered Services provided by Contracting or Noncontracting Dentists is determined using many factors, including pre-negotiated payment amounts, a calculation of charges submitted by Contracting Idaho Dentists, and/or a calculation of the average charges submitted by all Idaho Dentists.
A federal act that placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.
A jointly funded federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.
Your medical history is a record of all the conditions and illnesses that you and the members of your close family have or had. It helps your health care team know what your risks may be for developing certain medical problems or conditions.
A trust that individuals or employees of small businesses may establish to pay for out-of-pocket medical expenses.
The Covered Service or supply recommended by the treating Covered Provider to identify or treat an Insured’s condition, Disease, Illness or Accidental Injury and which is determined by Blue Cross of Idaho to be:
The fact that a Covered Provider may prescribe, order, recommend, or approve a service or supply does not, in and of itself, necessarily establish that such service or supply is Medically Necessary under this Policy. The term Medically Necessary as defined and used in this Policy is strictly limited to the application and interpretation of this Policy, and any determination of whether a service is Medically Necessary hereunder is made solely for the purpose of determining whether services rendered are Covered Services.
A federal government sponsored medical insurance plan primarily for elderly and disabled persons.
The part of Medicare that provides basic hospital insurance coverage automatically for most eligible persons.
A voluntary program that is part of Medicare and provides benefits to cover the costs of physicians' services.
The part of Medicare that expands the list of different types of entities allowed to offer health plans to Medicare beneficiaries. Also known as Medicare Advantage.
See Medicare Part C.
A private medical insurance plan that supplements Medicare coverage. Also known as a Medigap policy.
See Medicare Supplement.
Means and includes mental disorders, mental illnesses, psychiatric illnesses, mental conditions and psychiatric conditions. This includes, but is not limited to, the following conditions: psychoses, neurotic disorders, schizophrenic disorders, affective disorders, personality disorders and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems.
MRA stands for Magnetic Resonance Angiogram. An MRA is a kind of scan that takes pictures of the insides of the blood vessels. An MRA can show reduced blood flow and the build-up of plaque on the walls of the vessels.
The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members for a specified product or line of business.
A provider that has not entered into a written agreement with a specified insurer pertaining to payment for covered services rendered or provided to an insured under the program in which the insured is enrolled.
A person who is licensed and specializes in optometry to examine, measure and treat certain visual defects by means of corrective lenses or other methods that do not require a license as a physician.
Diagnostic and medical services to evaluate or identify an acceptable donor for a recipient and a donor's surgical and hospital services directly related to the removal of an organ or tissue for such purpose. Transportation for a donor or for a donated organ or tissue is not an organ procurement service.
Any Covered Services rendered by a Noncontracting Provider.
The maximum dollar amount of coinsurance paid by an insured in a benefit period after meeting the deductible before specified covered services are paid at 100% of the maximum allowance. See Total Out-of-pocket Maximum.
A patient who receives services or supplies while not an inpatient.
Outpatient care is care that does not include an overnight stay in a hospital. The care may be done in a clinic, a doctor’s office, or a hospital. You go home after the procedure and a short recovery period.
Specialized education services for insureds who are either newly diagnosed with diabetes or have had a recent complication of diabetes. Outpatient diabetes education includes instruction in the basic skills of diabetes management through books/educational material as well as an individual or group consultation with a certified diabetes educator, nurse or dietitian.
An intensive inpatient program administered by qualified health care professionals, under the orders of an attending physician, to a patient who is suffering chronic, intractable pain, regardless of its origin, which has failed to respond to medical or surgical treatment. Pain rehabilitation is intended to teach the patient how to control and cope with pain and regain normal function.
The pancreas is a small organ that lies between the stomach and the spine. It makes insulin, which controls the amount of sugar in your blood. It also makes other hormones (see above) and digestive juices that help the small intestine digest food.
The parathyroid is a group of four small glands that are attached to the back of the thyroid gland. The parathyroid glands make a hormone that helps the body maintain the correct balance of calcium and phosphorous.
The parotid glands are the largest of glands that make saliva. They lie in front of and slightly below the ears. Saliva is released into the mouth near the upper teeth.
Pertussis (whooping cough) is a very contagious bacterial disease of the upper respiratory system. It causes violent coughing and can cause serious complications, especially in infants and young children. The Tdap and DtaP vaccines protect against whooping cough.
A pelvic exam is a physical examination of the organs in a woman’s pelvis. The uterus, cervix, fallopian tubes, and ovaries (sex organs) are checked from the outside and through the vagina. The bladder and the rectum are also examined.
A PET scan is a test that shows how organs and tissue in the body are working. A small amount of radioactive tracer (see below) is injected into the blood and collects in the tissue. This allows doctors to see areas that do not look normal. PET stands for positron emission tomography.
A type of specialty service organization that seeks to contain the costs, while promoting safer and more efficient use of prescription drugs or pharmaceuticals. Also known as a prescription benefit management plan.
Medically necessary non-acute therapy rendered by qualified health care professionals, intended to restore a patient's physical health and well-being as close as reasonably possible to the level that existed immediately prior to the occurrence of a condition, disease, illness or accidental injury.
A written plan established and periodically reviewed by an attending physician, which describes the services and supplies for the physical rehabilitation care and treatment to be provided to a patient.
An individual licensed to practice physical therapy by the state where the service was rendered.
A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) licensed to practice medicine by the state where the service was rendered.
Plaque is a build-up of fatty substance on the inside walls of blood vessels. The plaque narrows the vessels and reduces or blocks the flow of blood. Plaque build-up can lead to heart attacks and strokes.
Pneumococcus is the bacteria that causes pneumococcal disease, which includes bacterial pneumonia and bacterial infections of the middle ear, the blood stream (bacteremia), and the covering of the brain (meningitis).
An individual licensed to practice podiatry by the state where the service was rendered.
A health care option that allows members of a managed care plan to choose at the time medical services are needed whether they will go to a provider within the plan's network or seek medical care outside the network.
A policy of insurance between an insurer and a person or entity.
The date specified in a policy on which coverage under the policy commences for the insured.
A polyp is a growth on the lining of the colon or other organ. Polyps become more common as people age.
An evaluation conducted by an insurer to determine the medical necessity of an insured's inpatient admission and attendant course of treatment.
Preadmission testing includes tests and studies required in connection with a patient's inpatient admission to a hospital that are rendered or accepted by the hospital on an outpatient basis prior to a scheduled inpatient admission to the hospital. For purposes of payment, preadmission testing and same day services related to an Inpatient case have been factored into Blue Cross of Idaho's inpatient payment systems for hospitals. Such services are not separately payable if rendered within 72 hours of the inpatient admission.
A condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the enrollment date. Under HIPAA guidelines, a pregnancy existing on the enrollment date is not a preexisting condition under group coverage. Pregnancy can be considered a preexisting condition under individual coverage. Genetic information is not considered a preexisting condition in the absence of a diagnosis of the condition related to such information.
A health care benefit arrangement designed to supply services at a discounted cost by providing incentives for members to use designated health care providers (who contract with the PPO at a discount), but which also provides coverage for services rendered by health care providers who are not part of the PPO network.
A prepaid payment or series of payments made to a health plan by purchasers, and often plan members, for medical benefits.
State income taxes levied on insurance premiums.
Drugs, biologicals and compounded prescriptions that can be dispensed only pursuant to a written prescription, that are listed with approval in the United States Pharmacopoeia, National Formulary or AMA Drug Evaluations published by the American Medical Association (AMA), that are prescribed for human consumption, and that are required by law to bear the legend: 'Caution-Federal Law prohibits dispensing without prescription.'
General medical care that is provided directly to a patient without referral from another physician. Primary care is focused on preventative care and the treatment of routine injuries and illnesses.
A person designated to give direct care and emotional support to an insured as part of a hospice plan of treatment. A primary care giver may be a spouse, relative, or other individual who has personal significance to the insured such as a neighbor or friend. A primary care giver must be a volunteer who does not charge a fee or expect or claim any other compensation for services provided to the insured.
A physician who serves as a group member's first contact with a plan's health care system. In Idaho, PCPs must include at a minimum family practice and general practice physicians, general internists, pediatricians, obstetricians, and gynecologists. Also known as a primary care provider.
A program that requires physicians or other health care providers to obtain certification of medical necessity prior to rendering a covered service. Also known as a medical necessity review.
The prostate is the male gland that makes part of the fluid (semen) that carries sperm. It is about the size of a walnut. The prostate lies just below the bladder and wraps around the urethra (see below).
A person or entity that is licensed, where required, to render or provide covered services as defined in the policy.
A facility provider which is principally engaged in providing diagnostic and therapeutic services and rehabilitative services for the inpatient treatment of mental or nervous conditions, alcoholism or substance abuse or addiction; and where such services are provided by or under the supervision of an organized staff of physicians, and continuous nursing services are provided under the supervision of a licensed registered nurse.
A psychiatrist is a medical doctor who has special training to diagnose and treat mental disorders. A psychiatrist can prescribe medicine.
A psychologist has a PhD or PsyD in psychology. A psychologist is licensed to do counseling (psychotherapy) or research. In most states, psychologists cannot prescribe medicine.
A committee responsible for oversight of an insurer's or managed care organization's quality management program including the setting of standards, review of data, feedback to providers, follow-up, and approval of sanctions and for the quality of care delivered to members.
"Creditable coverage" means, with respect to an individual, health benefits or coverage provided under any of the following:
A State Children’s Health Insurance Program (CHIP), under Title XXI of the Social Security Act, is creditable coverage, whether it is a stand-alone separate program, a CHIP Medicaid expansion program, or a combination program, and whether it is provided through a group health plan, health insurance, or any other mechanism.
CMS Insurance Standards Bulletin, Transmittal No. 05-01 clarified that:
"Any public health plan, including a plan established or maintained by the U. S. government, or a foreign country, is creditable coverage for purposes of identifying eligible individuals under Part B of Title XXVII of the Public Health Service Act (PHS Act)".
An organization-wide process of measuring and improving the quality of the health care provided by an insurer or managed care organization.
A radioactive tracer, called a radionuclide or an isotope, is a liquid with a small amount of radioactive material in it. When the tracer is swallowed or injected into the body, it spreads and collects in organs and/or bones. When a camera scans the body the tracer shows in the images. The way the tracer spreads or collects shows doctors where there may be disease or other problems.
A licensed general hospital that: (1) Is approved by the Medicare program for the requested transplant; (2) Is included in the Blue Cross and Blue Shield System’s National Transplant Network; (3) Has arrangements with another Blue Cross and/or Blue Shield Plan for the delivery of the requested transplant, based on appropriate approval criteria established by that plan; or (4) Is approved by the plan based on the recommendation of plan’s Medical Director.
The recovery room is a room in a hospital where patients recover from anesthesia after surgery. Nurses monitor the patient’s blood pressure, temperature, and other vital signs.
A managed care organization's authorization, based on the determination of a member's primary care physician and review by the managed care organization's medical review staff, to utilize specialty physician services for a specified regimen of care.
The reproductive organs are the sex organs. In the female, they include the vagina, uterus, ovaries, and fallopian tubes, which are inside the body, and the labia and clitoris, which are outside the body. In the male, they include the penis, the scrotum, and the testicles (testes), which are all outside the body.
Care provided to a homebound insured as part of a hospice plan of treatment for the purpose of providing the primary care giver a temporary period of rest from the stress and physical exhaustion involved in caring for the insured at home.
Robotic surgery is surgery by remote control, where the doctor sits at a computer and directs very small instruments inside the body.
Scintigraphy is an imaging test that shows the health of the bones and joints. A radioactive tracer (see above) is injected into a vein and travels to the bones. A camera takes pictures that show how much tracer collects in the bones. The images let the doctors see areas where bone is not normal.
The seminal vesicles are two glands near the male prostate (see above). They produce most of the fluid (semen) that carries sperm.
A sexually transmitted infection (STI) or disease is spread through vaginal, oral, or anal sexual contact. Bacteria, viruses, or parasites can cause STIs. There are more than 20 types of STIs, including chlamydia, herpes, syphilis, gonorrhea, HPV, and HIV. Many can be cured, but some cannot be.
A federal act which established as national policy the concept of a competitive marketing system by prohibiting companies from attempting to (1) monopolize any part of trade or commerce, or (2) engage in contracts, combinations, or conspiracies in restraint of trade. The Act applies to all companies engaged in interstate and/or foreign commerce.
Shingles is a painful, burning skin rash that is caused by the varicella-zoster virus, the virus that causes chickenpox. The virus remains inactive in certain nerves after chickenpox heals. It can become active again years later. The shingles vaccine protects against shingles.
The enrollment of only the enrollee under a policy.
Nursing services that must be furnished by or under the direct supervision of a licensed registered nurse (R.N.) to maximize the safety of a patient and to achieve the medically desired result pursuant to the orders and direction of an attending physician. The following components of skilled nursing care distinguish it from custodial care, which does not require professional health training: (1) the observation and assessment of the total medical needs of the patient; (2) the planning, organization and management of a treatment plan involving multiple services where specialized health care knowledge must be applied in order to attain the desired result; and (3) the rendering of direct nursing services to the patient where the ability to provide the services requires specialized training.
A facility provider that is principally engaged in providing inpatient skilled nursing care to patients requiring convalescent care rendered by or under the supervision of a physician. A skilled nursing facility is not, other than incidentally, a place or facility that provides minimal care, custodial care, ambulatory care, or part-time care services; or care or treatment of mental or nervous conditions, alcoholism, or substance abuse or addiction.
Any person, firm, corporation, partnership or association that is actively engaged in business that employed an average of at least two (2) eligible employees on the first day of the plan year, but no more than fifty (50) eligible employees, the majority of whom were employed within a given state. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of state taxation, are considered one employer.
A designated unit within a hospital that has concentrated facilities, equipment and support services for the provision of an intensive level of care for critically ill patients.
A physician whose scope of practice is concentrated in a specific, specialized field of medicine. In Idaho, specialist physician does not include family practice and general practice physicians, general internists, pediatricians, obstetricians, and gynecologists, who are considered primary care physicians.
The spinal cord is the band of nerves that runs down from the brain through the spine, or backbone. Nerves branch off from the spinal cord through openings in the vertebrae.
The spleen is an organ in the abdomen, between the stomach and the spine. The spleen contains white blood cells that fight infection. It also destroys old and damaged cells and helps fight some bacteria.
A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum.
A behavioral or physical disorder manifested by repeated excessive use of a drug or alcohol to the extent that it interferes with a person's health, social or economic functioning.
The performance, within the scope of a provider's license, of: (1) generally accepted operative and cutting procedures; (2) endoscopic examinations and other invasive procedures utilizing specialized instruments; (3) the correction of fractures and dislocations; and (4) customary preoperative and postoperative care.
Tetanus is a deadly bacterial infection of the nervous system. The bacteria enter the body through a wound or cut and make a poison. The poison causes violent muscle spasms. The Dt vaccine, also called a tetanus shot, protects against tetanus.
Therapy services include radiation therapy, chemotherapy, renal dialysis, physical therapy, respiration therapy, occupational therapy, speech therapy, enterostomal, growth hormone therapy, and home intravenous therapy.
The thoracic spine includes the 12 vertebrae between the neck and the lower back.
The thorax is the part of the body between the neck and the abdomen. It includes the heart and lungs, the breastbone, and the 12 thoracic vertebrae and ribs.
The thyroid is a gland that makes chemicals, called hormones, that help control the body’s metabolism—how the body uses food to get energy. The thyroid is shaped like a butterfly and is in the front of the neck, just above the collarbone.
A condition resulting from disease, illness, or injury by reason of which, and as certified in writing by an attending physician: (1) The insured is unable to perform the principal duties of regular employment or occupation for which the insured is or becomes qualified by reason of education, training, or experience; and the Insured is not in fact engaged in any work, profession, or vocation for fees, gain, or profit; or (2) An enrolled eligible dependent is so disabled and impaired thereby as to be unable to engage in the normal activities of an individual of the same age and gender.
The combined deductible and out-of-pocket payments made by an insured in a benefit period before specified covered benefits are paid at 100% of the maximum allowance.
See radioactive tracer
A health insurance program under which the insurer reimburses a contracting provider up to the insurer's maximum allowance less deductible, coinsurance, and copayments for each covered service rendered to the insured. Covered services rendered by noncontracting providers are reimbursed directly to the insured.
Surgical removal of a donated organ or tissue and the transfer of that organ or tissue to a recipient.
The enrollment of the enrollee and one eligible dependent under a policy.
An umbilical hernia is a bulge caused by part of the intestines pushing through the wall of the abdomen near the belly button. An umbilical hernia often heals in an infant by age 1. If it does not heal by age 4, surgery may be needed to close the opening in the wall of the abdomen.
The umbilicus is the area left on the belly when the umbilical cord is cut after birth. It is commonly called the belly button.
Managing the use of medical services to ensure that a patient receives necessary, appropriate, high-quality care in a cost-effective manner.
The evaluation of the medical necessity, efficiency and/or appropriateness of health care services and treatment plans.
A vaccine is a medicine that protects the body against a serious disease. The vaccine is usually made from weak or dead forms of the disease. These cause the body’s immune system to produce antibodies to the disease, and the antibodies prevent the disease from entering the body.
A virus is a tiny organism that can only grow in living cells in the body. Viruses cause many infections in people, including colds, flu, hepatitis, and HIV/AIDS.
A state-mandated insurance program that provides benefits for health care costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease.