Glossary

Agent

An independent representative licensed to sell and service Blue Cross plans.

Allergist

A specialist who studies allergies, or the body's reaction to substances, situations, or physical states that don't affect the average person.

Allowed amount

The dollar amount that a health plan determines is appropriate for a covered service. Blue Cross network health care providers have agreed to accept the allowed amount as full payment, which means you pay less for your care.

Amount paid by other insurance

The amount paid by another health plan, such as Medicare or a spouse’s health plan.

Anesthesiology

A branch of medicine that involves pain management and support of a patient's life functions during anesthesia and surgery.

Appeal

A formal request by a member or health care provider to reconsider a decision about a service, a benefit payment or an administrative action.

Asynchronous

Communication that has a delay in response between a patient and a healthcare provider who are in separate locations. Example: Emails, text messages, and faxes

Audiology

A branch of science dealing with hearing.

Behavioral health care

The practice of evaluating and treating mental health, chemical dependency disorders, autism and eating disorders.

Cardiology

Diagnosis and treatment of diseases of the heart and blood vessels.

Cardiovascular disease

A disease relating to, or involving, the heart and blood vessels.

Case manager

An experienced health care professional (nurse, doctor or social worker) who works with patients, providers and plans to coordinate care for individual patients.

Chiropractic

Treatment to restore normal function through manipulation and adjustment; particularly of the spinal column.

Claim

Information provided by a health care provider or a member to establish that medical services were provided. Blue Cross network providers submit claims for their patients.

Coinsurance

The percent of covered health care costs that a member pays.

Coordination of benefits

If a member is eligible to receive benefits under this plan and another group plan, we’ll coordinate benefits with the other plan. Coordination of benefits means one plan pays first (is primary) and one plan pays second (is secondary). This prevents overpayment of charges. When coordinating benefits, the total payment to a health care provider will not be more than 100 percent of the covered cost.

Copay

A payment, usually a fixed amount, that you make on a per-service basis.

Credentialing

The process of reviewing providers who apply to participate in a health plan to make sure they meet the plan's requirements.

Deductible

The annual amount you pay toward eligible health care services each year before your health plan pays on your behalf.

Dependent

A spouse, domestic partner or a child who is enrolled as part of another member’s health plan.

Dermatology

Diagnosis and treatment of disorders of the skin.

Diagnostic services

X-ray, laboratory and pathology services that help diagnose or treat an illness or injury.

Durable medical equipment

Medical equipment that is able to withstand repeated use and is used primarily for a medical purpose. Examples are wheelchairs, crutches and hospital beds.

Eligibility

The conditions a person must satisfy to be covered by the health plan contract.

Eligible charges

Services that are covered according to the health plan contract.

Emergency

A sickness or injury so serious that failure to get immediate care could put a person's life in danger or cause serious harm. Some examples are possible heart attack (severe chest pain or pressure), uncontrollable bleeding, breathing problems, poisoning and unconsciousness.

Endocrinology

A science dealing with the endocrine glands, which produce secretions that help control metabolic activity.

E-visits

E-visits are shorter, non-urgent virtual appointments for common health problems like sore throats, colds, flu or rashes. E-visits are typically not with your usual primary care provider and usually occur over phone, electronic messaging or video. There is usually a set cost that is provided before the appointment is scheduled. E-visit costs are typically less than an appointment with your primary care physician or nurse practitioner. 

Experimental procedures

Any services, supplies, treatments, procedures or devices that are determined by the health plan to be not generally accepted by informed health care professionals in the United States as effective in treating the condition for which their use is proposed or not scientifically proven to be effective in treating the condition.

Explanation of health care benefits (EOB)

A notice sent from the health plan to the member describing the resolution of a claim. It includes services provided, amount billed, payment made and any costs that are the member's responsibility.

Family practice

A medical specialty that focuses on health care for the entire family, including obstetric care and minor surgical procedures.

Fully insured

A benefit plan offered by a company in which the insurance company pays for the member's health care claims and sets the plan benefits. 

Gastroenterology

Diagnosis and treatment of stomach, intestine, liver and pancreas diseases.

General practitioner

A physician who does not limit his or her field of practice to a specialty.

Geriatrics

Diagnosis and treatment of diseases and conditions specific to aging.

Gynecology

Medical and surgical treatment for disorders and diseases of the female reproductive and urinary systems.

Health care provider

A hospital, clinic, physician or other facility that provides health care services.

Health cost summary

A statement that shows health plan and any financial account use and costs for calendar year-to-date. The summary is for a subscriber and any covered dependents.

Health plan responsibility

The amount or portion of the total charge for health care services that the health plan is responsible for.

Health risk assessment

A confidential tool that helps employees identify their individual health risks and offers suggestions to reduce those risks.

Home health care

Services provided in the home to aged, disabled, sick or convalescent people who don't require institutional care. Services are provided by a home health agency, visiting nurse, or other hospital or community group.

Hospice

A facility or program that provides supportive care for people who are terminally ill.

ID card

See Member ID card.

Immunization center

A location where providers administer vaccinations, such as a public health center, pharmacy or mall. May also include a physician office setting.

Immunology

The study of immunity and immune responses.

Inpatient

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

Internal medicine

A medical specialty focusing on the prevention, diagnosis and treatment of diseases affecting adults.

Long-term care insurance

Coverage designed to reduce the risk that the contract holder would need to deplete his or her assets to pay for long-term care.

Medically necessary

Health care services and supplies that are evaluated as appropriate and necessary based on diagnosis and cost-effectiveness, and that are consistent with national medical practice guidelines on type, frequency and length of treatment.

Medical policy

Documentation that provides medical necessity and coverage guidelines for our members.

Medicare supplement

Supplementary coverage, available to persons eligible for Medicare, to help pay remaining balances after Medicare has made payment.

Medigap insurance

Private insurance policies that supplement Medicare and cover the difference between what Medicare pays and the allowed charges for covered and uncovered services.

Member

A person covered by a health plan.

Member ID

The identification number assigned to a member.

Member ID card

A card that identifies members of a plan. It lists the identification number, group number and effective date of the plan and includes important phone numbers.

Member responsibility

The amount the member is responsible for of the total charge for health care services received.

Neonatology

Diagnosis and treatment of disorders in newborns.

Nephrology

Diagnosis and treatment of fluid and electrolyte disorders and hypertension, including kidney disorders.

Network

The hospitals, physicians and other medical professionals who sign a contract with a health plan to provide care for its members. Also referred to as participating or in-network providers.

Neurology

Diagnosis and treatment of diseases and injuries of the nervous system (brain, spinal cord, nerves), medically rather than surgically.

Nurse midwife

A licensed health care professional who provides gynecological services and care for women during and after normal pregnancy and labor.

Nurse practitioner

A licensed registered nurse who has gained additional knowledge and skills through an organized program of study and clinical experience.

Obstetrics

Health care during and after a woman's pregnancy.

Obstetrics/gynecology (ob/gyn)

The medical specialty that focuses on women's health care issues like pregnancy, childbirth, family planning and annual checkups.

Occupational therapy

A branch of medicine that involves a program of activities to help patients regain a degree of independence or return to employment.

Office

Location, such as a clinic, where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury.

Oncology

The medical science or specialty concerned with the diagnosis and treatment of tumors, commonly various forms of cancer.

Open-access plans

Benefit plans that allow members to see network providers for specialty care without a referral from another doctor.

Open enrollment

The period of time when an employee may change enrollment status or benefit plans, usually without evidence of good health or waiting periods.

Ophthalmology

Diagnosis and treatment of glaucoma and muscle disorders of the eye, including cataract surgery and laser treatment, and vision evaluation and prescribing of corrective lenses.

Optometry

The art or profession of examining the eye for defects and prescribing corrective lenses or exercises to correct the defect.

Oral and maxillofacial surgery

Diagnosis and treatment of disorders of the mouth, teeth, jaws and facial structures, including surgical correction of facial deformities and fractures.

Oral surgery

Field of dentistry dealing with surgery of the mouth and its related structures.

Orthopedic surgery

A branch of medicine that involves surgical treatment of skeletal deformities and injuries.

Orthotics

Specialized field relating to orthopedic appliances, braces and other devices used to support weight, prevent or correct deformities, or align and improve the function of movable parts of the body.

Osteopath

Similar to medical doctors, osteopaths (also referred to as doctors of osteopathic medicine or DOs) emphasize the role of the bones, muscles and joints in the healthy functioning of the human body.

Otolaryngology

The diagnosis and treatment, medically and surgically, of diseases and disorders of the ear, nose and throat. Also referred to as ENT.

Out of network

The option to see health care providers who don't have a contract with the health plan. When benefit plans include this option, members share more of the cost when receiving care from out-of-network providers.

Out-of-pocket costs

The portion of health care costs that a member is responsible for, including copays, coinsurance, deductibles and noncovered services.

Out-of-pocket maximum

The most a member will pay each year toward allowed health care costs. Once the out-of-pocket maximum is reached, the health plan pays 100 percent until the end of the calendar or benefit year.

Outpatient

A portion of a hospital that provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

Pediatrics

The prevention, diagnosis and treatment of diseases in children, from birth through the teenage years.

Pharmacy

A facility or location where drugs and other medically related items and services are sold, dispensed or otherwise provided directly to patients.

Physiatry

The diagnosis, treatment and prevention of disease with the aid of physical agents such as light, heat, cold and water, or with medical apparatus. Physiatry is focused on rehabilitative medicine.

Physical therapy

Treatment of bodily ailments and muscular function through various physical and nonmedicinal means (the use of heat, water, exercise, massage and electric current, for example).

Physician

A licensed doctor of medicine with full training in traditional medical practice. Physicians undergo a broad-based medical school education, extensive experience in residency and a comprehensive series of medical board examinations prior to being licensed.

Plastic surgery

Plastic surgical procedures fall into two major subdivisions: reconstructive procedures, which involve the restoration of form, and in many cases function, of body parts that are abnormal due to injury, disease, or congenital defects, and cosmetic procedures, which are performed to enhance the appearance of body parts that fall within the normal range of appearance and function.

Podiatry

The diagnosis and treatment of disorders of the feet.

Point-of-service plan

A type of benefit plan that lets the member choose health services from in-network primary care or out-of-network health care providers at the time care is needed, with different benefit levels.

Preexisting condition

A condition, injury or sickness considered to be a condition requiring medical treatment that existed before the effective date of a health plan contract. If a condition is preexisting, it may not be covered for a specific period of time under some contracts.

Premium

The amount paid to a health plan company for providing coverage under a contract. Often you pay a portion of the total, which is deducted from your paycheck, and your employer pays the rest.

Primary care

Basic or general health care usually provided by general practitioners, family practitioners, internists and pediatricians.

Primary care clinic

The clinic a member chooses to coordinate his or her health care services.

Prior authorization

Prior authorization, sometimes called PA or pre-certification, is how the health plan company makes sure the treatment your doctor prescribes is medically necessary. We use established clinical guidelines to confirm medical necessity when your health plan contract requires prior authorization.

Prosthetics

The study of artificial limbs — their design, construction and fitting to a patient.

Provider

Any individual or group that provides a health care service, such as doctors, hospitals, group practices, nursing homes or pharmacies.

Provider responsibility amount

The amount that the cost of health care services is reduced based on a contract between the health plan and the provider.

Psychiatry

The study, diagnosis, treatment and prevention of mental illness.

Psychologist

A practitioner of clinical psychology, counseling or guidance.

Psychotherapy

The psychological techniques used in behavioral health care.

Pulmonary medicine

Diagnosis and treatment of lung diseases and conditions such as bronchitis, emphysema and cancer.

Radiology

A branch of medicine concerned with the use of X-rays and radium in the diagnosis and treatment of disease.

Referral

Advance approval from a primary care provider for a patient to see a specialist.

Remote patient monitoring

Provider is using technology to collect information about a patient's health. Example: Insulin pump reporting blood glucose readings to a health care provider; vital signs such as blood pressure readings or weight.

Rheumatology

The diagnosis and treatment of muscle and joint diseases and conditions, particularly arthritis.

Self insured

A benefit plan offered by a company in which the employer pays for the member's health care claims and sets the plan benefits. 

Skilled nursing facility

A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but does not provide the level of care or treatment available in a hospital.

Specialist

A doctor with specialized medical training.

Speech therapy

The therapeutic treatment of speech defects, such as lisping and stuttering.

Sports medicine

A medical specialty concerned with the prevention and treatment of injuries and diseases that are related to participation in sports.

Subscriber

The person whose employment is the basis for the health plan and who is responsible for payment of premiums.

Synchronous

Exchange of health information in real time, typically provided with an audio or video technology to allow a live discussion between a patient and a healthcare provider. Example: Video or phone calls between a patient and healthcare provider in separate locations. 

Telehealth (a.k.a. telemedicine, televideo, telecare)

Telehealth is when a patient and a healthcare provider are in separate locations and use a video and audio connection to interact in real time. They are a good option for minor illnesses, follow-up visits, mental health and more. Cost varies by provider, but a telehealth appointment is typically a similar cost as an in-person office visit. 

Virtual care

This is a broad term that encompasses many types of care that is not accomplished in-person with a medical professional. This includes e-visits and telehealth (a.k.a. telemedicine, televideo or telecare) via message, phone, or video. Cost varies by provider and plan. 

Urology

A branch of medicine that involves diagnosis and treatment of diseases and disorders of the kidneys, bladder and urinary tract. Also includes the treatment of disorders affecting the male reproductive organs.