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 amount Blue Cross has agreed to pay a specific provider for a covered service.

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 healthcare 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 healthcare

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 healthcare 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

A request for prior approval of a covered service or for the payment or reimbursement of the charges or costs associated with a covered service.

Coinsurance

This payment structure starts after meeting your deductible. In coinsurance, you and the plan each pay a percentage for covered services. Example: 80/20 coinsurance means the plan pays 80 percent and you pay 20 percent.

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 healthcare provider will not be more than 100 percent of the covered cost.

Copay

A fee you pay every time you get care or a prescription. Copays can vary based on where you get care (virtual, clinic, urgent care, etc.).

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 dollar amount you must pay for most covered services each calendar year before the health plan begins to pay for benefits.

Dependent

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

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 (DME)

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 short, non-urgent virtual appointments for common health problems like sore throats, colds, flu or rashes. E-visits are typically not with your primary care provider. E-visit costs are typically less than an in-person appointment with your primary care provider or a nurse practitioner. More on virtual care.

Experimental procedures

The use of any treatment, service, procedure, facility, equipment, prescription drug, device or supply (intervention) which is determined by Blue Cross to not be medically effective for the condition being treated or not scientifically proven to be effective in treating the condition.

Explanation of healthcare 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 healthcare 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 healthcare 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.

Healthcare provider

A hospital, clinic, physician or other facility that provides healthcare 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 healthcare 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 healthcare

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

Supportive care services provided at home or in an inpatient hospital setting 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 care

Care that provides round-the-clock registered nursing services for short-term medical and behavioral health services in a hospital setting.

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 and appropriate

Services provided to a member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. Services are evaluated according to diagnosis and cost-effectiveness, 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 healthcare 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 healthcare 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

This is the last milestone you hit by paying for covered medical services. Once you reach this amount, the plan pays for all covered in-network services for the remainder of the plan year.

Outpatient care

Services received without being admitted for an inpatient stay. Services received at an ambulatory surgery center are considered outpatient care.

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 doctor of medicine (MD), osteopathy (DO), dental surgery (DDS), medical dentistry (DMD), podiatric medicine (DPM), or optometry (OD) practicing within the scope of their license. 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 healthcare 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 healthcare usually provided by general practitioners, family practitioners, internists and pediatricians.

Primary care clinic

The clinic where a member chooses to coordinate their healthcare 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

Doctors, clinics, hospitals, pharmacies and other healthcare professionals and facilities.

Provider responsibility amount

The amount that the cost of healthcare 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 healthcare.

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 healthcare 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 healthcare claims and sets the plan benefits. 

Skilled nursing facility

A Medicare-approved 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

Telehealth allows patients and providers in different locations to interact in real time through a video and audio connection. 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. More on virtual care.

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. More on virtual care.

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.