Basic Health Care Terms

Ambulance

a specially designed and equipped vehicle used only for transporting the sick and injured.

Ambulatory Surgical Facility

an institution which:

• primarily performs surgical procedures on an outpatient basis;
• does not provide inpatient care;
• has an organized staff of physicians and permanent facilities and equipment;
• may not be primarily used as an office or clinic for a doctor's or other professional's private practice; and
• is a licensed institution.

Appeal

An official written request, made by a doctor or other provider, to review a benefit determination or reimbursement. Members may appeal by using the member grievance process.

Applicant

A person who completes and submits an application to receive health plan coverage. You remain an applicant until the effective date that your coverage begins.

 

Balance Billing

A doctor, hospital or other caregiver may sometimes bill more for a service than the maximum allowable charge for that service. If you use the doctors and hospitals in your plan network, they are not allowed to bill you for the balance of that amount, and you are not responsible for the extra charge. If you use doctors and hospitals that do not participate in your health plan network, you may be responsible for the balance billed amount.

Benefit

 A health care benefit is that part of the cost of your care that is paid out or reimbursed on your behalf by BlueCross BlueShield of Tennessee. Your benefit includes actual payments made and the network savings you receive by using network providers. Example: If your plan has a $20 copay for an office visit with a network doctor, your benefit is the remaining amount of the doctor's charges for that office visit. If you pay a 20 percent coinsurance amount for network providers with your PPO plan, your benefit is the remaining balance. Remember: Using out-of-network services reduces your benefits and increases the amount you may have to pay.

Benefit Period

a calendar year during which benefits are available for covered services.

 

Blue Network C

One of four PPO provider network choices offered by BlueCross BlueShield of Tennessee. Blue Network C includes hospitals, ambulatory surgical facilities, doctors, practitioners, rehabilitation facilities, hospice, skilled nursing facilities, durable medical equipment suppliers, independent labs and home health agencies in Tennessee and some bordering counties. If you select Blue Network C, use the online provider directory to make sure that any and all health care providers you choose participate in Blue Network C (formerly known as BlueClassic network).

 

Blue Network P

One of four PPO provider network choices offered by BlueCross BlueShield of Tennessee. Blue Network P offers a wide variety of credentialed practitioners, hospitals and other health care providers as well as all participating pharmacies. This comprehensive PPO network includes facilities (acute care hospitals and ambulatory surgical facilities) as well as doctors, practitioners, rehabilitation facilities, hospice, skilled nursing facilities, durable medical equipment suppliers, independent labs and home health agencies in Tennessee and some bordering counties. If you select Blue Network P, use the online provider directory to make sure that any and all health care providers you choose participate in Blue Network P (formerly known as BluePreferred network).

Blue Network S

One of four PPO provider network choices from BlueCross BlueShield of Tennessee. Blue Network S includes hospitals, ambulatory surgical facilities, doctors, practitioners, rehabilitation facilities, hospice, skilled nursing facilities, durable medical equipment suppliers, independent labs and home health agencies in Tennessee and some bordering counties. If you select Blue Network S, use the online provider directory to make sure that any and all health care providers you choose participate in Blue Network S (formerly known as BlueSelect network).

BlueCard Program

a program established by Blue Cross and/or Blue Shield organizations and the Blue Cross and Blue Shield Association to process and pay claims for covered services received by a member of a Blue Cross and/or Blue Shield organization from a provider outside the organization’s service area.

 

Broker

A licensed insurance professional who offers advice and assistance to people or companies who wish to purchase health plan coverage.

Case Management

An added level of benefit service for critical injuries or complex illness. Case management helps coordinate your care -- before, during and after treatment or surgery -- to make sure special needs are met, and appropriate services and care sites are used.

Claim

A request for payment of benefits under the terms of your health plan. When you use doctors, hospitals and caregivers in your network, they file your claims for you.

Class of Expenses

includes:

• Class I Expense means eligible hospital provider or facility other provider charges.
• Class II Expense means:
  a. an eligible expense for services rendered by a physician or professional other provider whose services are in connection with a Class I expense; or
  b. an eligible expense for a surgical procedure performed by a physician or professional other provider in or out of a hospital.
• Class III Expense means all other eligible charges not included as a Class I or Class II Expense.

Coinsurance

the portion of an eligible medical bill a member must pay out of pocket before BlueCross BlueShield of Tennessee begins paying insurance benefits. Coinsurance amounts are usually a percentage of the total eligible medical bill, such as 20 percent. Coinsurance applies after the member meets a required deductible or copay amount. Coinsurance is part of certain health care plans.

 

Concurrent Review

a determination of whether continued inpatient care, or a given level of services being received, is medically necessary for the patient’s medical condition. This review can be performed by the provider’s utilization review staff, our review coordinator, our medical director or other entity or organization under contract to us. If this review determines that continued inpatient care is no longer medically necessary, the patient, facility and physician will be notified in writing of a specific date when benefits will cease. The patient or physician can appeal the decision by contacting us. We will review the case and notify the physician and the patient of the results.

Copay/Copayment:

a copay is a fixed-dollar amount that a plan member pays to a participating network doctor, caregiver, or other medical provider or pharmacy each time health care services are received. A copay is paid before BlueCross BlueShield of Tennessee pays the covered benefit amount. Copays are part of certain health care plans.

 

Contract

the entire agreement between BlueCross BlueShield of Tennessee and the Subscriber. It includes a contract document, the signed application, and any attached papers or riders. A rider is an extra provision we add to the basic Contract. We consider the statements a customer makes in the application to be representations and not warranties.

Contract Date or Effective Date

the date coverage begins.

Covered

Medical services you receive are considered covered when they qualify for payment or reimbursement under the terms of your specific health plan.

Covered Service

a Medically Necessary service or supply shown in the Contract for which benefits may be available.

Custodial Care

care provided primarily for maintenance designed to assist the patient in activities of daily living. It is not provided primarily for its therapeutic value in treatment of an illness or injury. Custodial Care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets, and supervision of self-administration of medication not requiring constant attention of medical personnel.

Deductible or deductible amount

a deductible is a fixed-dollar amount that a plan member must pay for eligible services before BlueCross BlueShield of Tennessee begins applying insurance benefits. Usually deductibles apply every calendar year. Deductibles are part of certain health care plans.

Dependent

another family member covered under a person's health insurance plan. May be a spouse and unmarried children who meet eligibility requirements of the plan.

Diagnostic Service

a procedure ordered by a physician or other provider to determine a specific condition or disease. Some common diagnostic procedures include:

• X-rays and other radiology services;
• laboratory and pathology services; and
• cardiographic, encephalographic, and radioisotope tests.

 

Disease Management

Programs and services that provide extra information and assistance to people with chronic illnesses. Disease management can help people better manage their chronic illness and symptoms, and stay on track with the prescribed treatment plan. Typically, disease management services are provided free of charge to plan members.

 

Durable Medical Equipment (DME)

A certain type of health care equipment that may be a part of your treatment. These items can only be used for a specific medical purpose, are made to withstand repeated use, are appropriate to use at home, and are of little or no use to someone without injury or illness. Examples include hospital beds, wheelchairs and oxygen equipment.

e-Health Services®

See Member Self-Service.

Effective Date

the date on which coverage begins for a member.

Elective Drug (or Non-Preferred Brand Drug)

A brand-name drug that is not included on your Preferred Drug List . Many different brand drugs may be available to treat a medical condition. When you or your doctor choose an elective (or non-preferred brand) drug, you will pay the highest copay amount.

Eligibility

Your qualification to enroll in a group-sponsored health plan, apply for coverage under an individual plan, or receive the appropriate benefits as outlined in your plan.

Eligible Person

a person entitled to make application for coverage as a Subscriber.

Emergency or Emergency Medical Condition

an emergency is the sudden occurrence of a medical condition so severe that, without immediate medical attention, the condition could reasonably be expected to cause serious impairment to bodily functions, serious dysfunction of a bodily organ, or otherwise place the member's health in serious danger. For behavioral health benefits, an emergency is a sudden or rapidly escalating behavioral condition that, without immediate psychiatric or substance abuse attention, could reasonably be expected to cause serious emotional or physical dysfunction, or otherwise place the member's or others' health and well being in serious danger.

 

Emergency Admission

admission as an Inpatient in connection with an Emergency.

Emergency Services

health care services and supplies furnished in a Hospital which are needed to determine, evaluate and/or treat an Emergency Medical Condition until the Condition is stabilized, as directed or ordered by a Physician or Hospital protocol.

ERISA (Employee Retirement Income Security Act)

A federal law enacted in 1974 to provide minimum standards of protection for people in most voluntarily established private industry pension and health plans. ERISA requires plans to provide participants with information about the plan, its features and funding. The regulations outline responsibilities for those that manage and control plan assets, and require plans to establish a grievance and appeals process for participants. There are several amendments to ERISA -- including COBRA and HIPAA -- which expand the protections available to health benefit plan participants and beneficiaries. Governmental groups are exempt from ERISA regulations.

Exclusions

Medical services that do not qualify for payment or reimbursement by your health plan and are not included in your health plan coverage. Any exclusion is listed in your contract, Evidence of Coverage, Member Handbook, or Summary Plan Description.

Experimental/Investigational

A drug, device, treatment, therapy, procedure, or other services or supply that does not meet the definition of Medical Necessity:

• cannot be lawfully marketed without the approval of the Food and Drug Administration ("FDA") when such approval has not been granted at that time of its use or proposed use, or
• is the subject of a current Investigational new drug or new device application on file with the FDA, or
• is being provided according the Phase I or Phase II clinical trial or the experimental or research portion of a Phase III clinical trial ( provided, however, that participation in a clinical trial shall not be the sole basis for denial), or
• is being provided according to a written protocol which describes among its objectives, determining the safety, toxicity, efficacy or effectiveness of that service or supply in comparison with convention alternatives, or
• is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board ("IRB") as required and defined by Federal regulations, particularly those of the FDA or the Department of Health and Human Services ("HHS"), or
• The Office of Health Care Technology Assessment within the Agency for Health Care Policy and Research within HHS has determined that the service or supply is either experimental or investigational or that there is insufficient data to determine if it is clinically acceptable, or
• in the predominant opinion of experts, as expressed in the published authoritative literature, that usage should be substantially confined to research settings, or
• in the predominant opinion of experts, as expressed in the published authoritative literature, further research is necessary in order to define safety, toxicity, efficacy, or effectiveness of that Service compared with conventional alternatives, or

1. the service or supply is required to treat a complication of an Experimental or Investigational Service.

The Medical Director shall have discretionary authority, in accordance with applicable ERISA standards, to make a determination concerning whether a service or supply is an Experimental or Investigational Service. If the Medical Director does not Authorize the provision of a service or supply, it will not be a Covered Service. In making such determinations, the Medical Director shall rely upon any or all of the following, at his or her discretion:

• Your medical records, or
• the protocol(s) under which proposed service or supply is to be delivered, or
• any consent document that You have executed or will be asked to execute, in order to received the proposed service or supply, or
• the published authoritative medical or scientific literature regarding the proposed service or supply in connection with the treatment of injuries or illnesses such as those experienced by You, or
• regulations or other official publications issued by the FDA and HHS, or
• the opinions of any entities that contract with the Plan to assess and coordinate the treatment of Members requiring non-Experimental or Investigational Services, or
• the findings of the Blue Cross and Blue Shield Association Technology Evaluation Center or other similar qualified evaluation entities.

Family Coverage

coverage of a Subscriber and one or more eligible Dependents as defined in the Schedule of Eligibility.

Family Deductible

the maximum dollar amount of Covered Services stated in the Schedule of Benefits that must be incurred and paid by a Subscriber and his or her eligible Dependents before benefits can be paid for all or part of the remaining Covered Services.

 

Family Out-of-Pocket Maximum

the dollar amount stated in the Schedule of Benefits for which a Subscriber and his or her covered eligible Dependents are responsible to pay for Covered Services during a Benefit Period.

Formulary

The prescription drug formulary is an extensive list of drug choices that are commonly prescribed by doctors based on the drugs' proven effectiveness, safety and cost. If you have prescription drug benefits, the drug formulary is an important reference guide for you and your doctor, and can help save you money. The formulary is divided into tiers or levels that indicate different copay costs for generic drugs, preferred brand drugs, or elective drugs.

Freestanding Diagnostic Laboratory

an Other Provider which provides laboratory analysis for Other Providers.

 

Freestanding Dialysis Facility

a Facility Other Provider which provides dialysis treatment, maintenance, and training to patients on an Outpatient or Home Health Care basis.

Generic Drug

A prescription drug that is made and sold by a drug firm under its general formula name. Generic drugs are not protected by a patent or registered tradename. But they are required by the FDA to have the same quality, safety and effectiveness standards as brand-name drugs. Generic versions  of many higher-priced brand drugs are usually available to treat the same medical condition. In almost all cases, you save money and pay the lowest copay amount when you or your doctor request generic drugs.

Grievance

An official written request, made by a plan member, to review a decision about benefit coverage or claim payment.

Group Administrator

The person at a place of business who helps design and purchase group health coverage for the company's employees, and manage ongoing details about the plan. This could be a benefits manager, human resources manager, or any other company official given this duty.

Group Health Coverage

A health plan that covers a group of people, such as the employees of a business or members of an organization. In most group plans, the employer pays the majority of the monthly coverage amount and employees contribute a smaller amount.

Health Care Professional

a Podiatrist, Dentist, Chiropractor, Nurse Midwife, Registered Nurse, Optometrist, or other person licensed or certified to practice a health care profession, other than medicine or osteopathy, by Tennessee or the state in which that Provider practices.

HIPAA (Health Insurance Portability and Accountability Act)

HIPAA is a federal law enacted in 1996 that includes important provisions for people who are self-employed, who move from one job to another, or who have pre-existing medical conditions. It is designed to improve health plan portability and availability by:

• Providing better access to health plan coverage for people who change or lose their jobs
• Limiting exclusions for pre-existing conditions
• Prohibiting discrimination against employees and dependents based on their health status
• Providing guaranteed renewability and availability of health coverage to certain employees and individuals

New HIPAA regulations for administrative simplification begin to take effect in 2003. In brief, the new regulations are designed to:

• Enhance the privacy and security of a member's personal health information
• Enhance and maintain the secure exchange and storage of that information
• Standardize the electronic processes and information coding used when personal health information is exchanged between providers, health insurers and appropriate business associates

Home Health Care Agency

an Other Provider which is primarily engaged in providing home health care services.

Hospital

a short-term, acute-care, general hospital which:

• is a licensed institution;
• provides inpatient services and is compensated by or on behalf of its patients;
• provides surgical and medical facilities primarily to diagnose, treat, and care for the injured and sick; except that a psychiatric hospital will not be required to have surgical facilities;
• has a staff of physicians licensed to practice medicine; and
• provides 24-hour nursing care by registered graduate nurses.

A facility which serves, other than incidentally, as a nursing home, custodial care home, health resort, rest home, rehabilitative facility or place for the aged is not considered a hospital.

Host Plan

a Blue Cross and/or Blue Shield organization that has a contract with a provider that provides services to its subscribers outside of the Blue Cross Blue Shield of Tennessee service area.

ID Card

A health plan identification card that is sent to you once your enrollment form is accepted. It is personalized with your member number, provider network name, customer service number, and copay amounts, if copays are part of your plan. The back of your card has instructions on what to do before receiving certain types of health care services.

Individual Health Coverage

 A health plan that you purchase on your own to provide ongoing health coverage for you and any eligible dependents. Individual health plans are also available for short-term coverage needs if you are a recent graduate looking for work, or between jobs and waiting for work.

In Network

doctors, caregivers and medical facilities are considered "in network" if they participate in an agreement with BlueCross BlueShield of Tennessee to provide services according to specific terms and rates. Your benefit level when using the providers in your health plan's network is referred to as "in-network" on your benefit summary chart.

In Plan

in an HMO or POS program, you receive the highest level of benefits when the services you receive are "in plan," or follow a certain approval process. If your PCP submits a valid standard referral to send you to another provider for services, your benefits will be considered "in plan" if you are referred to another in-network provider. You may also receive in-plan benefits if a referral to an out-of-network provider is approved by BlueCross BlueShield of Tennessee.

Inpatient

inpatient medical care is when treatment is provided to a member who is admitted as a bed patient in a hospital or other medical facility, and room and board charges are incurred. For behavioral health benefits, inpatient care can refer to treatment received at a hospital, a behavioral health facility or a behavioral health program. Most benefit plans require prior authorization for inpatient care before a plan member is admitted to a hospital, skilled nursing facility or rehabilitation facility.

 

Limiting Age (or Dependent Limiting Age)

the age after which a child will no longer be considered an eligible Dependent, according to the Schedule of Eligibility.

Maintenance Drug List

The maintenance drug list includes certain drugs commonly prescribed to treat illnesses that are chronic, long-term and stable. The drugs on the list are chosen based on their proven effectiveness, safety and cost, and are available in up to a 100-day supply. If you have prescription drug benefits, the maintenance drug list is an important reference guide for you and your doctor, and can help save you money.

Maximum Allowable Charge (MAC)

The highest dollar amount that will be paid to a doctor, hospital or other caregiver as payment for a covered medical service. For doctors who participate in a network from BlueCross BlueShield of Tennessee, this amount is based on negotiated fees. For those who do not participate in a network, the amount may differ.

 

Maximum Lifetime Amount

the total dollar amount of benefits available for Covered Services under a Member’s Contract during the Member’s lifetime, as stated in the Schedule of Benefits.

Medical Care

professional services by a Physician or Professional Other Provider to treat an illness, injury, pregnancy, or other medical condition.

Medical Underwriting

the review by BCBST of a prospective Member’s health history and physical/medical condition for the purpose of determining insurability for coverage under this Contract (based on BCBST underwriting guidelines).

Medically Necessary (or Medical Necessity)

Services which have been determined by the Plan to be of proven value for use in the general population. To be Medically Necessary a service must:

• Have final approval from the appropriate government regulatory bodies.
• Have scientific evidence permitting conclusions concerning the effect of the service on health outcomes.
• Improve the net health outcome.
• Be as beneficial as any established alternative.
• Demonstrate the improvement outside the investigational setting.
• Not be an experimental or investigational service.

 

Medicare

the program of health care for the aged and disabled established by Title XVIII of the Social Security Act as amended.

 

Member

any person covered under a health plan from BlueCross BlueShield of Tennessee, including that person's eligible spouse and/or eligible, unmarried children. May be addressed as "You" and "Your."

 

Member Self-Service

An easy-to-use online resource at bcbst.com that gives you instant access anytime to detailed information about your particular benefit plan and coverage. With Member Self-Service, you can review your benefit and coverage details, including applied deductibles and out-of-pocket limits. You can also check

Nervous and Mental Disorder

a condition characterized by abnormal functioning of the mind or emotions in which psychological, intellectual, emotional or behavioral disturbances are the dominant feature. Nervous and Mental Disorders include mental disorders, mental illnesses, psychiatric illnesses, mental conditions, and psychiatric conditions, whether organic or non-organic, whether of biological, non-biological, genetic, chemical or non-chemical origin, and irrespective of cause, basis or inducement. Nervous and mental disorders include alcohol, drug or chemical abuse or dependency, but do not include learning disabilities, attitudinal disorders, or disciplinary problems.

Network (or Provider Network)

The doctors, hospitals and other health care providers that participate in contract agreements with BlueCross BlueShield of Tennessee. You will always receive the highest level of benefits when using providers that participate in your specific network. Choosing services from providers that do not participate in your particular provider network will increase the amount that you pay for those services.

Network Directory (or Provider Directory)

A complete listing of the doctors, hospitals and other health care providers that participate in a specific provider network. When you enroll, you may receive a printed directory for your network. However, you can check the most current provider directory anytime on the BlueCross BlueShield of Tennessee Web site or contact customer service. Always check your provider directory or contact customer service to make sure that any and all health care providers you choose participate in your specific network.

 

Non-Covered

Medical services you receive are considered non-covered when they do not qualify for payment or reimbursement under the terms of your specific health plan, or they are excluded from coverage under your plan.

Non-Preferred Brand Drug (or Elective Drug)

A brand-name drug that is not included on your Preferred Drug List . Many different brand drugs may be available to treat a medical condition. When you or your doctor choose a non-preferred brand (or elective) drug, you will pay the highest copay amount.

Non-Preferred Care Provider

a physician, hospital or ambulatory surgical facility that has not contracted with BlueCross BlueShield of Tennessee to furnish services and to accept specified levels of payment, plus applicable deductibles and copayments, as payment in full for covered services.

Open Enrollment

The time, once a year, when your employer or group health plan lets you make changes in your coverage. Typically, this is the time to add or delete dependents from your coverage, select different types of coverage if offered, change your network if others are offered, or enroll in the group health plan if you elected not to join in the past. The choices you make at open enrollment are locked in for the next year. Only certain specific events -- such as marriage, birth or adoption, and the termination of a spouse's employment -- qualify you to add dependents to your coverage throughout the year. In most cases, these requests must be made within 31 days after the wedding, birth or job change in order to ensure coverage. Check your Evidence of Coverage or Member Handbook for your specific plan details.

Out-of-Pocket Maximum

The highest dollar amount you will need to pay on your own each year for covered medical services from network providers, including coinsurance and deductibles. Once you reach the out-of-pocket maximum for the year (if your plan includes this feature), your health plan reimburses your network caregivers for any remaining covered services that year, up to the lifetime maximum amount. Depending on your plan, using out-of-network providers may affect an out-of-pocket maximum and increase the amount you pay. Non-covered services, copay amounts and amounts over the maximum allowable charge do not apply to an out-of-pocket maximum. Not all plans have an out-of-pocket maximum or a lifetime max.

Other Provider

an individual or facility, other than a Hospital or Physician, duly licensed to render Covered Services.

1. The following institutions are facility other providers which may provide Covered Services:

• Freestanding Dialysis Facility
• Ambulatory Surgical Facility;
• Skilled Nursing Facility;
• Substance Abuse Treatment Facility;
• Residential Treatment Facility;
• Licensed Birthing Center.

2. The following professional other providers may provide services covered by certain BCBST Contracts. In order to be covered, all services rendered must fall within a specialty (as defined below) and be those normally provided by a Provider within this specialty or degree. All services or supplies must be rendered by the Provider actually billing for them and be within the scope of his or her Licensure.

• Doctor of Osteopathy (O.D.);
• Doctor of Dental Surgery (D.D.S.);
• Doctor of Dental Medicine (D.M.D.);
• Doctor of Optometry (O.D.);
• Doctor of Podiatric Medicine (D.P.M.);
• Doctor of Chiropractic (D.C.);
• Licensed Clinical Social Worker;
• Licensed Independent Practitioners of Social Work;
• Registered Nurse (R.N.), including an R.N. who is a nationally-certified Nurse Practitioner, Nurse Anesthetist or Clinical Specialist;
• Registered Nurse Anesthetist (R.N.A.);
• Licensed Practical Nurse (L.P.N.);
• Nurse Midwife, licensed as an R.N. and certified by the American College of Nurse Midwives;
• Licensed Psychologist designated by law as a health service Provider;
• Licensed Psychological Examiner supervised in accordance with Tennessee law;
• Registered Physiotherapist (R.P.T.);
• Licensed Pharmacist (D. Pharm.); and
• Occupational Therapist (for services to restore functioning of the hand following trauma only).
• Registered Dietitian or Nutritionist approved by BCBST (for nutritional counseling in connection with the treatment of diabetes only)

3. The following Other Providers may also provide services covered by certain BCBST Contracts:

• suppliers of durable medical equipment, appliances and prosthesis;
• suppliers of oxygen;
• certified ambulance service;
• Hospice;
• Pharmacy;
• Freestanding Diagnostic Laboratory; and/or
• Home Health Care Agency.

 

Out of Network

doctors, caregivers and medical facilities are considered "out of network" if they do not participate in an agreement with BlueCross BlueShield of Tennessee to provide services according to specific terms and rates. Your benefit level available when using the providers in your health plan's network is referred to as "out-of-network" on your benefit summary chart.

Out of Plan

reduced benefits, or "out-of-plan" benefits, take effect when a POS member seeks care from a provider without a valid approved referral. Benefits are reduced even if the provider selected is in the network, but benefits will be substantially reduced if the provider is considered out of network. In both cases, the member may incur substantial out-of-pocket costs.

Out-Of-Pocket Maximum

the dollar amount stated in the Schedule of Benefits which a member must pay for covered services during a benefit period (except this will not include psychiatric care services).

Outpatient

outpatient medical care is when treatment is provided to a member in a facility or setting where room and board charges are not incurred. Outpatient medical services may be provided in a doctor's office, the outpatient department of a hospital, or in some other medical setting. For behavioral health benefits, outpatient care refers to routine visits to a behavioral health professional. Most benefit plans require prior authorization for certain outpatient medical services.

 

Outpatient Surgery

surgery performed in an outpatient department of a hospital, Physician's office or Facility Other Provider.

 

Physical Therapist

a licensed physical therapist. (In states where there is no licensure required, the physical therapist must be certified by the appropriate professional body or accrediting organization.)

Physician

a licensed physician legally entitled to practice medicine and perform Surgery. All Physicians must be licensed in Tennessee or in the state in which Covered Services are rendered.

Point of Service (POS)

in a POS plan, members receive the highest level of benefits when they have their medical care coordinated by the Primary Care Practitioner (PCP) they select. Referrals are required in a POS plan. Without a referral, members receive a lower level of benefits when they receive care from any other provider. POS plans require members to select a PCP.

Practitioner

A doctor, physician assistant, or other health care professional that provides or coordinates the health care services you receive.

Pre-Admission Certification Program

those reporting and review requirements designed to encourage the delivery of required services in the most medically appropriate setting.

Pre-Existing Condition Waiting Period

the period stated in the Schedule of Benefits (beginning with the Effective Date of coverage under a Contract) during which services rendered in connection with a Pre-Existing Condition are not payable.

Preferred Brand Drugs

Brand-name drugs that are medically sound, cost-effective alternatives to other higher-priced drugs. If you have a three-tier drug plan, you will pay a reduced copay when you or your doctor choose brand drugs from the Preferred Drug List  instead of non-preferred drugs, also called elective drugs.

Preferred Drug List: A convenient listing of the preferred brand drugs and generic medications that help save you money on your prescription costs. Depending on your drug plan and copay levels, your savings could be considerable. You may receive a copy of the Preferred Drug List  when you enroll. However, the list is available online  for you and your doctor to check anytime.

Preferred Provider

a physician, hospital, or ambulatory surgical facility or other health care provider that has contracted with Blue Cross and Blue Shield of Tennessee to furnish services and to accept our payment for covered services after applicable deductibles, coinsurance or co-payments have been paid by the Member.

Preferred Provider Organization (PPO)

a PPO plan offers a network of doctors, caregivers and medical facilities that agree to provide health care services to plan members at less than their usual service fees so that members save money using the network. Members receive the highest level of benefits from their PPO plan when network providers are used. Members may also seek medical care outside of the network, but substantially reduced benefits and higher out-of-pocket expenses may result.

Pre-Treatment Certification

those reporting and review requirements which apply in connection with certain Covered Services under a Contract (as specified in the Schedule of Benefits) in order to encourage the delivery of such services in the most medically appropriate setting.

Primary Care Practitioner (PCP)

the doctor you select to coordinate all your health care, including routine checkups and treatment for medical problems. Your PCP participates in a network of doctors, caregivers and medical facilities that are part of your health plan coverage. A PCP is usually a doctor in general practice, family practice, internal medicine or pediatrics. Certain health plans require you to select a PCP.

Prior Approval

see explanation of "prior authorization."

Prior Authorization

prior authorization verifies the medical necessity of certain treatments, as well as the setting where medical services are provided. Your health plan information may also refer to prior authorization as "prior approval." With pharmacy benefits, prior authorization can also help determine cost-effective alternatives for certain prescription drugs.

Provider

your provider is the doctor or other professional caregiver that supplies your health care. A medical facility, such as a hospital or health center, medical supplier or home health agency, is also called a provider.

Psychiatric Care

 treatment of a nervous or mental disorder as defined in a Contract. Psychiatric Care can include treatment for drug addiction or alcoholism

Referral

the process by which an HMO patient’s primary care doctor authorizes treatment from a medical specialist

Skilled Nursing Facility

a facility which provides convalescent and rehabilitative care on an Inpatient basis. Skilled nursing care must be provided by or under the supervision of a Physician.

Neither

• a facility which primarily provides minimal, custodial, ambulatory, or part-time care, nor
• a facility which treats mental illness, alcoholism, drug abuse or pulmonary tuberculosis

is considered a Skilled Nursing Facility under certain BCBST Contracts.

Specialist

A doctor who is trained to diagnose and treat specific diseases, diagnose and treat conditions within certain areas of the body, or care for people at a certain age.

Specialist Physician

The term specialist physician may refer to a sub-specialist in complex cases that require either surgery or the expertise of a physician highly trained in a specific area. Some examples of specialists include cardiologists, dermatologists, neurologists, obstetricians, podiatrists, psychiatrists, etc.

Subscriber

an employee enrolled in an employer group health plan from BlueCross BlueShield of Tennessee, or an individual who purchases personal health insurance offered by BlueCross BlueShield of Tennessee. May be addressed as "You" and "Your."

Surgery

means the following:

• operative and cutting procedures, including use of special instruments;
• endoscopic examinations (the insertion of a tube to study internal organs), and other invasive procedures;
• treatment of broken and dislocated bones;
• usual and related pre- and post-operative care when billed as part of the charge for Surgery; and
• other procedures that have been approved by BCBST.

Termination Date

the date a Contract ends and the date benefits end.

Therapy Services

the following services for treatment of illness or injury:

• radiation therapy - treatment of disease by X-ray, radium, or radioactive isotopes;
• chemotherapy - treatment of malignant disease by chemical or biological agents;
• dialysis - treatment of a kidney ailment, including the use of an artificial kidney machine;
• physical therapy - treatment to relieve pain, restore bodily function, and prevent disability following illness, injury, or loss of a body part;
• respiratory therapy - introduction of dry or moist gases into the lungs; and
• home infusion therapy - therapy in which fluid or medication is given intravenously. It includes total parenteral nutrition, enteral nutrition, hydration therapy, chemotherapy, aerosol therapy and intravenous drug administration.