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Provider and Facility Reference Manual

Section 19 - Glossary



The patient's ability to obtain medical care;  the ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care.

The process by which an agency or organization evaluates and recognizes a program of study or an institution as meeting certain predetermined standards. Accreditation is usually given by a private organization created for the purpose of assuring the public of the quality of the accredited (such as the Joint Commission on Accreditation of Hospitals).

Acute Care
Health care delivered to patients experiencing an illness or health problem of a short-term or episodic nature. This term is used in contrast to the term "continuing care," which is often used to describe nursing homes or home health care.

Processing claims according to contract.

To make a correction on a claim or an account.

Administrative Services Organization (ASO)
A contract between an insurance company and a self-funded plan where the insurance company performs administrative services only and the self-funded entity assumes all risk.

Entry to a hospital as a patient, on an inpatient or outpatient basis.

Age Limit
Stated age(s) whereby eligibility for membership or benefits participation is determined.

Allowed Amount
Maximum dollar amount assigned for a procedure based on various pricing mechanisms, also known as a maximum allowable.

Ambulatory Care
Health services provided without the patient being admitted to a hospital. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading.

Ancillary Services
Professional charges for x-ray, laboratory tests, and other similar patient services.

Average Generic Price (AGP)
The average reimbursement for medications that are off-patent and available from more than one manufacturer.

Average Wholesale Price (AWP)
The standardized cost of a pharmaceutical calculated by averaging the cost of an undiscounted pharmaceutical charged to a pharmacy provider by a large group of pharmaceutical wholesale suppliers.


Refers either to a covered service under a particular contract or the dollar amount paid for a covered service.

Benefit Levels
The limit or degree of services a person is entitled to receive based on his/her contract with a health plan or insurer.

Benefit Package
Services an insurer, government agency, or health plan offers to a group or individual under the terms of a contract.

BlueCard® Program
A process that allows participating and Blue Cross and/or Blue Shield Plans to adjudicate claims for members who receive hospital or medical care from a participating facility/provider located outside of their Plan's operating area.

Board Certified
Describes a physician who has passed a written and oral examination given by a medical specialty board and who has been certified as a specialist in that area.

Board Eligible
Describes a physician who is eligible to take the specialty board examination by virtue of having graduated from an approved medical school, completing a specific type and length of training, and practicing for a specified amount of time.


Calendar Year
The period of time from January 1 of any year through December 31 of the same year; most often used in connection with deductible amount provisions of major medical plans providing benefits for expenses incurred within the calendar year. Also found in provisions outlining benefits in basic hospital, surgical, medical plans.

A payment method in which a pre-determined amount is paid to a provider to deliver care to an individual; the payment is generally made monthly and the provider is responsible for the delivery of a specific range of health services for this set payment, regardless of actual cost of services.

A company that sells insurance coverage or that markets prepaid health and medical coverage, such as a Blue Cross and Blue Shield Plan or an independent private insurance company.

Case Management
The process by which all health-related matters of a case are managed by a physician, nurse or designated health professional. Physician case managers coordinate designated components of health care, such as appropriate referrals to consultants, specialists, hospitals, ancillary providers and other services. Case management is intended to ensure continuity of services and accessibility to overcome rigidity, fragmented services, and the misutilization of facilities and resources. It also attempts to match the appropriate intensity of services with the patient's needs over time.

Case Mix
The relative frequency and intensity of hospital admissions or services reflecting different needs and uses of hospital resources; case mix can be measured based on patients' diagnoses or the severity of their illnesses, the utilization of services, and the characteristics of a hospital.

A request for payment for health care services rendered.

The standard form used by the Centers for Medicare and Medicaid Services for submitting physician service claims to third party (insurance) companies.

A requirement under a health insurance contract by which the member shares a stated portion of his/her cost of care.

Comprehensive Major Medical Insurance
A policy designed to provide the protection offered by both a basic and major medical health insurance policy. It is generally characterized by a low deductible, a coinsurance feature, and high maximum benefits.

Concurrent Review
Utilization review activities conducted by insurers to determine the medical necessity and coverage of health care services, procedures, or treatments proposed to be rendered or being rendered to a member.

An uninterrupted stay for a defined period of time in a hospital, skilled nursing facility or other approved health care facility or program followed by discharge from that same facility or program.

Contract Year
A period of 12 consecutive months, commencing with each anniversary date for member eligibility; may or may not coincide with a calendar year.

Coordination of Benefits (COB)
A clause in many insurance contracts that applies to group contract holders who have more than one contract covering the same services; a determination is made as to which contract is primary and which is secondary. The primary carrier pays first and any covered balances are then considered by the secondary carrier. The object is to guarantee that the insured is paid no more than the total charges when duplicate coverage exists, thereby eliminating the profit motive.

A cost sharing arrangement in which the HMO enrollee pays a specified flat amount for a specific service. It does not vary with the cost of the service, unlike coinsurance, which is based on a percentage of cost.

CPT™ (Current Procedural Terminology)
A classification system developed by the American Medical Association in which unique codes are assigned to procedures and services (but not diagnoses) performed by providers.

A process of review to approve a provider who applies to participate in a health plan; specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.

Custodial Care
The medical or non-medical services, which do not seek to cure, that are provided during periods when the medical condition of the patient is not changing, or do not require the continued administration by medical personnel. For example: assistance in the activities of daily living.


Date of Service
The date on which health care services were provided to the covered person.

A dollar amount required to be paid by the insured under a health insurance contract, before benefits become payable.

Deductible Carry-Over Credit
Any covered charge that is incurred during October, November or December and is applied toward the deductible for that year, will also be carried over and applied to the following year's deductible.

A person other than the contract holder who is covered under a contract.

Medical management while an individual withdraws from alcohol or chemical dependency.

The identification of a disease or condition through analysis and examination.

Diagnosis Codes
See International Classification of Diseases (ICD-10).

Discharge Planning
The evaluation of a patient's medical needs in order to arrange for appropriate care after discharge from an inpatient setting.

Drug Formulary
A list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the guidance of a pharmacy and therapeutics committee. In HMOs, members may only have coverage for medications listed on a formulary.

Durable Medical Equipment (DME)
Products designed to help patients maintain maximum independence to continue living at home and to enhance the quality of life for both patients and caregivers.


Effective Date
The date a policy goes into effect.

Qualified for coverage.

Emergency Care
Care for patients with severe or life-threatening conditions that require intervention within minutes or hours.

A provision in the contract stating situations or conditions under which coverage is not afforded; i.e., No-Fault, Workers' Compensation.

Expedited Appeal
A process used for adverse determinations involving continued or extended health care services, procedures, or additional services for a continued course of treatment; or when the provider believes an immediate appeal is warranted, except in the case of retrospective reviews.

Explanation of Benefits
A statement sent to a member that explains what action was taken on a claim.


Fee for Service
A method of payment that provides reimbursement, usually in pre-determined amounts, upon the occasion of the provision of a specific service; fee-for-service payments occur each time a service is rendered.

Fee Schedule
A listing of accepted fees or established allowances for specified medical procedures; as used in medical care plans, it usually represents the maximum amounts the program will pay for the specified procedures.


Grievance Procedure
A grievance is a request to change a contractual determination other than a determination that a service is not medically necessary or is experimental of investigational. Examples of benefit determinations include denial of a referral or denial of coverage for a referred service, or any determination that a person is not eligible for coverage under the contract.


HCPCS (Health Care Procedure Coding System)
The Health Care Financing Administration's Common Procedure Coding System, which includes the AMA's complete CPT™ and lists procedure codes for other categories of service such as durable medical equipment. HCPCS also includes a range of local codes for services not otherwise identified.

Health Maintenance Organization (HMO)
HMOs offer comprehensive health coverage for both hospital and physician services. HMOs contract with health care providers, e.g., physicians, hospitals, and other health professionals, and members are required to use participating providers for all health services. Model types include staff, group practice, network and IPA.

Healthcare Effectiveness Data and Information Set (HEDIS)
A set of performance measures designed to standardize the way health plans report data to employers. HEDIS currently measures five major areas of health plan performance: quality, access and patient satisfaction, membership and utilization, finance, and descriptive information on health plan management.

Hold Harmless Clause
A clause frequently found in managed care contracts whereby the HMO and the physician do not hold each other liable for malpractice or corporate malfeasance if either of the parties is found to be liable. Many insurance carriers exclude this type of liability from coverage. It may also refer to language that prohibits the provider from billing patients under certain circumstances. State and federal regulations may require this language.

Home Health Care
Full range of medical and other health-related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient, by a provider.

Home Claims
Claims for a Blue Cross Blue Shield member who receives hospital or medical care from a participating provider of another Blue Cross and/or Blue Shield Plan.

Home Plan
A plan participating in the BlueCard® program whose member receives hospital and/or medical care in the area of another plan.

A program of care that treats terminally ill patients and their families; the program, which is designed for patients with a prognosis of six months or less to live, provides coordinated, interdisciplinary inpatient and home care services, and emphasizes pain control and psychological well-being.

Hospital Affiliation
A contractual agreement between an HMO and one or more hospitals whereby the hospital provides the inpatient benefits offered by the HMO.

Host Claims
Claims for members of other Blue Cross and/or Blue Shield Plans who receive hospital or medical care from a participating provider of Highmark Blue Cross Blue Shield of Western New York.

Host Plan
A Plan participating in the BlueCard® Program that extends hospital and/or medical care to a Blue Cross Blue Shield member.


Identification Card
The card issued by the Plan as evidence of membership.

Identification Number
A unique number assigned to each member by the health plan.

Individual Practice Association (IPA)
A health care model that contracts with an individual practice association entity to provide health care services in return for a negotiated fee; the individual practice associations in turn contracts with physicians who continue in their existing individual or group practices. The individual practice association may compensate the physicians on a per capita, fee schedule, or fee-for-service basis.

Inpatient Care
Care given to a registered bed patient in a hospital, nursing home or other medical or post- acute institution.

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
A system used to classify and code all diagnoses, symptoms, and procedures; is used to code and classify mortality data from death. ICD-10-CM is the replacement for ICD-9-CM, effective October 1, 2015.


Managed Care
A system of health care delivery that influences utilization of services, cost of services and measures performance. The goal is a system that delivers value by giving people access to quality, cost-effective health care.

Medical Necessity
A service or treatment which is appropriate and consistent with diagnosis, and which, in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member's condition or the quality of medical care rendered.

A Federal entitlement program created in 1965 that provides medical benefits to people over age 65, people who have received Social Security disability payments for more than two years, and people with end-stage renal disease.


National Committee for Quality Assurance (NCQA)
A nonprofit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.


Out-of-Area (OOA)
A term describing the treatment obtained by a covered person outside the Plan's operating service area.

Out-of-Pocket Maximum
The total payments toward eligible expenses that a covered person funds for him/herself and/or his/her dependents: (deductibles, copays, and coinsurance) as defined per the contract. Once the maximum is reached, benefits will increase to 100 percent for health services received during the rest of that plan year. Some out-of-pocket costs (e.g. mental health, penalties for non-authorization, etc.) are not eligible for out-of-pocket limits.

An inpatient stay that exceeds expected cost or length-of-stay thresholds and thereby becomes eligible for additional reimbursement under a prospective payment system.

Outpatient Care
Care given to a person who has not been admitted to the hospital.


Palliative Care
Care that is intended to relieve physical pain and address spiritual, psychological, and social needs, as opposed to contributing to a cure.

Patient Liability
The dollar amount that an insured individual is legally obligated to pay for services rendered by a provider.

Participating Provider
A provider who has entered into a contract with a health plan to provide medical care to covered members.

A government agency, insurer, or health plan that pays for health care services.

Peer Review
A mechanism used by medical staff to evaluate the quality of health care provided by the health plan. The evaluation covers how well services are performed by all health personnel and how appropriate the services are to meet patients' needs.

Per Member Per Month (PMPM)
A unit of measure used by HMOs for a variety of purposes, including capitation payment.

Place of Service
The location where a medical service was provided, such as inpatient hospital, outpatient hospital or doctor's office.

Point of Service Plan (POS)
Also known as an open-ended HMO, POS plans encourage, but do not require, members to choose a primary care physician. As in traditional HMOs, the primary care physician acts as a "gatekeeper" when making referrals; plan members may, however, choose to visit non network providers at their discretion. Members choosing not to use the primary care physician must pay higher deductibles and copays than when using network physicians.

A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed.

Pre-existing Condition
A physical condition that existed prior to the effective date of a member's policy or enrollment in the Plan and may be subject to a limitation in the contract on coverage or benefits.

Preferred Provider Organization (PPO)
A managed care type of product that is offered by indemnity insurers or self-insured plans and provides enrollees the option of receiving services from participating or non-participating providers. The benefits packages are designed to encourage the use of participating providers by imposing higher deductibles and/or coinsurance for services provided by non-participating providers.

Primary Care Physician (PCP)
The PCP is the physician selected by the member and is responsible for monitoring the member's care and coordinating the delivery of all health care services.

Protected Health Information (PHI)
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), PHI is a term used to refer to individually identifiable health information that is transmitted electronically or maintained in any other form or medium.


Quality Assurance (QA)
Activities and programs intended to assure customers of the quality of care in a defined medical setting. Such programs include peer or utilization review components to identify and remedy deficiencies in quality. The program must have a mechanism for assessing its effectiveness and may measure care against pre-established standards.


The process of sending a patient from one practitioner to another for health care services; Health plans may require that designated primary care providers authorize a referral for coverage of specialty services.

Resource Based Relative Value Scale (RBRVS)
The classification system that is the basis for the Medicare physician fee schedule; the system assigns to physician services relative value units that incorporate resource consumption for 1) a work component that reflects the physician's skill and time required in furnishing the service, 2) a practice expense component that reflects general practice expenses, such as office rent and wages of personnel, and 3) a malpractice expense component.

Retrospective Review
Utilization review activities conducted by insurers to determine the medical necessity and coverage of health care services, procedures, or treatments that have already been provided to an enrollee.

A provision added to a contract that expands or limits the benefits that are otherwise payable.


Skilled Nursing Facility
A licensed institution as defined by Medicare that is primarily engaged in the provision of skilled nursing care.

Standard Appeal
A process where a provider or member can dispute an adverse decision based on medical necessity.

Stop Loss
A designated amount of eligible expenses that must be incurred by the member before payment can be made at 100 percent.

Stop Loss (Physicians)
A set dollar amount that is determined by the number of members within a physician's practice; if a member's health costs exceed this determined amount, the costs will be excluded from the calculation of the physician's actual per member per month expenditures.

Subacute Care
A level of care usually requiring a length of stay longer than short-term acute care and shorter than long-term skilled nursing care; an organized program of care for patients with either intense rehabilitative or medically complex needs, subacute care is focused on achieving specified measurable outcomes, using an interdisciplinary, case management approach, and providing care in an efficient and low-cost manner.

Means by which claims are identified as the responsibility of another insurer since treatment of the condition resulted from the action of an outside party.


Type of Service
Refers to services provided to a patient such as surgery, anesthesia, diagnostic x-ray, etc.


UB 04 Claim Form
Bill form used to submit hospital insurance claims for payment by third parties. Similar to CMS 1500 claim form, but reserved for inpatient and outpatient services.

Urgent Care
Medical care that requires prompt attention but is not life-threatening (i.e. earache, rash, etc.)

Usual and Customary
A term used to describe the average charge for a service.

Utilization Management Review
A program designed to reduce the incidence of unnecessary or inappropriate use of hospital and/or doctor's services. It is used for both cost control and quality assurance.


Workers' Compensation
A state mandated program providing insurance coverage for work related injuries and disabilities.