Provider Directory

Term Glossary

This glossary section is provided to help you understand terms that are used frequently by the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Service Benefit Plan brochure (RI 71-005). All benefits are subject to the definitions limitations and exclusions set forth in the Federal brochure.

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A C D E G I L M P R S T U Y

Definitions of terms used by the Service Benefit Plan

A

Accidental injury

An injury caused by an external force or element such as a blow or fall that requires immediate medical attention, including animal bites and poisonings. Note: Injuries to the teeth while eating are not considered accidental injuries. Dental care for accidental injury is limited to dental treatment necessary to repair sound natural teeth.

Admission

The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the same day.

Assignment

An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay you, the enrollee, directly for all covered services.

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C

Calendar year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Carrier

The Blue Cross Blue Shield Association, on behalf of the local Blue Cross and Blue Shield member companies.

Case management

A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s health needs through communication and available resources to promote quality, cost-effective outcomes (Case Management Society of America, 2012). Each Blue Cross and Blue Shield Plan administers a case management program to assist Service Benefit Plan members with certain complex and/or chronic health issues. Each program is staffed by licensed health care professionals (Case Managers) and is accredited by URAC or NCQA. For additional information regarding case management, call us at the telephone number listed on the back of your Service Benefit Plan ID card.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts.

Copayment

A copayment is a fixed amount of money you pay when you receive covered services.

Cosmetic surgery

Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form, except for repair of accidental injury or to restore or correct a part of the body that has been altered as a result of disease or surgery or to correct a congenital anomaly.

Cost-sharing

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance and copayments) for the covered care you receive.

Covered services

Services we provide benefits for, as described in the Service Benefit Plan brochure.

Custodial care

Facility-based care that does not require access to the full spectrum of services performed by licensed health care professionals that is available 24 hours-a-day in acute inpatient hospital settings to avoid imminent, serious, medical or psychiatric consequences. By “facility-based,” we mean services provided in a hospital, long term care facility, extended care facility, skilled nursing facility, residential treatment facility, school, halfway house, group home, or any other facility providing skilled or unskilled treatment or services to individuals whose conditions have been stabilized. Custodial or long term care can also be provided in the patient’s home, however defined.

Custodial or long term care may include services that a person not medically skilled could perform safely and reasonably with minimal training, or that mainly assist the patient with daily living activities, such as: :

  1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube or gastrostomy), exercising or dressing
  2. Homemaking, such as preparing meals or special diets
  3. Moving the patient
  4. Acting as companion or sitter
  5. Supervising medication that can usually be self-administered
  6. Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature and respiration; or administration and monitoring of feeding systems

We do not provide benefits for custodial or long term care, regardless of who recommends the care or where it is provided. The Carrier, its medical staff, and/or an independent medical review determine which services are custodial or long term care.

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D

Deductible

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies in a calendar year before we start paying benefits for those services.

Durable medical equipment

Equipment and supplies that:

  • Are prescribed by your physician (i.e., the physician who is treating your illness or injury)
  • Are medically necessary
  • Are primarily and customarily used only for a medical purpose
  • Are generally useful only to a person with an illness or injury
  • Are designed for prolonged use
  • Serve a specific therapeutic purpose in the treatment of an illness or injury

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E

Experimental or investigational services

Experimental or investigational shall mean:

a. A drug, device, or biological product that cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and approval for marketing has not been given at the time it is furnished; or

 b. Reliable evidence shows that the health care service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or

 c. Reliable evidence shows that the consensus of opinion among experts regarding the health care service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or

 d. Reliable evidence shows that the health care service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) does not improve net health outcome, is not as beneficial as any established alternatives, or does not produce improvement outside of the research setting.

Reliable evidence shall mean only evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations, such as:

 a. Published reports and articles in the authoritative medical and scientific literature;

 b. The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or

 c. The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical treatment of procedure.

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G

Group health coverage

Health care coverage that you are eligible for based on your employment or your membership in or connection with a particular organization or group, that provides payment for medical services or supplies or that pays a specific amount of more than $200 per day for hospitalization (including extension of any of these benefits through COBRA).

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I

Intensive outpatient care

A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental health and/or substance abuse conditions. It is an intermediate setting between traditional outpatient therapy and partial hospitalization, typically performed in an outpatient facility or outpatient professional office setting. Program sessions may occur more than one day per week. Timeframes and frequency will vary based upon diagnosis and severity of illness.

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L

Local PlanA Blue Cross and/or Blue Shield Plan that serves a specific geographic area.

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M

Medical necessity

All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine that the criteria for medical necessity are met. Medical necessity shall mean health care services that a physician, hospital, or other covered professional or facility provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

 a. In accordance with generally accepted standards of medical practice in the United States; and

b. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and

c. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and

d. Not part of or associated with scholastic education or vocational training of the patient; and

e. In the case of inpatient care, only provided safely in the acute inpatient hospital setting.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations.

 The fact that one of our covered physicians, hospitals, or other professional or facility providers has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary or covered under this Plan.

Mental conditions/substance abuse

Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychoses, neurotic disorders or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for abuse of or dependence upon, substances such as alcohol, narcotics or hallucinogens.

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P

Partial hospitalization

An intensive facility-based treatment program during which an interdisciplinary team provides care related to mental health and/or substance abuse conditions. Program sessions may occur more than one day per week and may be full or half days, evenings and/or weekends. The duration of care per session is less than 24 hours. Timeframes and frequency will vary based upon diagnosis and severity of illness.

Plan allowance

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. If the amount your provider bills for covered services is less than our allowance, we base our payment and your share (coinsurance, deductible and/or copayments), on the billed amount. We determine our allowance as follows:

  • PPO providers — Our allowance (which we may refer to as the "PPA" for "Preferred Provider Allowance") is the negotiated amount that Preferred providers (hospitals and other facilities, physicians and other covered healthcare professionals that contract with each local Blue Cross and Blue Shield Plan and retail and Internet pharmacies that contract with Caremark) have agreed to accept as payment in full, when we pay primary benefits.

    Our PPO allowance includes any known discounts that can be accurately calculated at the time your claim is processed. For PPO facilities, we sometimes refer to our allowance as the "Preferred rate." The Preferred rate may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf.

  • Participating providers — Our allowance (which we may refer to as the "PAR" for "Participating Provider Allowance") is the negotiated amount that these providers (hospitals and other facilities, physicians and other covered healthcare professionals that contract with some local Blue Cross and Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For facilities, we sometimes refer to our allowance as the "Member rate." The member rate includes any known discounts that can be accurately calculated at the time your claim is processed and may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf.

  • Non-participating providers — We have no agreements with these providers. We determine our allowance as follows:
    • For inpatient services at hospitals, and other facilities that do not contract with your local Blue Cross and Blue Shield Plan ("Non-member facilities"), our allowance is based on the average amount paid nationally to contracting and non-contracting facilities for covered room, board and ancillary charges for your type of admission. For inpatient stays resulting from medical emergencies or accidental injuries or for routine deliveries, our allowance is the billed amount

    • For outpatient, non-emergency surgical services at hospitals and other facilities that do not contract with your local Blue Cross and Blue Shield Plan ("Non-member facilities"), our allowance is the average amount for outpatient surgical services that we pay nationally to contracting and non-contracting facilities. For other outpatient services by Non-member facilities and for outpatient surgical services resulting from a medical emergency or accidental injury, our allowance is the billed amount (minus any amounts for noncovered services)

    • For physicians and other covered healthcare professionals that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the greater of 1) the Medicare participating fee schedule amount for the service or supply in the geographic area in which it was performed or obtained (or 60% of the billed charge if there is no equivalent Medicare fee schedule amount) or 2) 100% of the 2008 Usual, Customary and Reasonable (UCR) amount for the service or supply in the geographic area in which it was performed or obtained. Local Plans determine the UCR amount in different ways. Contact your Local Plan if you need more information. We may refer to our allowance for Non-participating providers as the "NPA" (for "Non-participating Provider Allowance")

    • For prescription drugs furnished by retail and Internet pharmacies that do not contract with Caremark, our allowance is the average wholesale price (AWP) of a drug on the date it is dispensed, as set forth in the most current version of First DataBank's National Drug Data File

    • For services you receive outside of the United States, Puerto Rico, and the U.S. Virgin Islands from providers that do not contract with us or with AXA Assistance, we use our Overseas Fee Schedule to determine our allowance. Our fee schedule is based on a percentage of the amounts we allow for Non-participating providers in the Washington, DC, area.

Non-participating providers are under no obligation to accept our allowance as payment in full. If you use Non-participating providers, you will be responsible for any difference between our payment and the billed amount (except in certain circumstances — see page 147 of the Service Benefit Plan Brochure). In addition, you will be responsible for any applicable deductible, coinsurance or copayment amounts.

Note: For certain covered services from Non-participating professional providers, your responsibility for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be limited.

In only those situations listed below, when the difference between the NPA and the billed amount for covered Non-participating professional care is greater than $5,000 for an episode of care, your responsibility will be limited to $5,000 (in addition to any applicable deductible, coinsurance or copayment amounts). An episode of care is defined as all covered Non-participating professional services you receive during an emergency room visit, an outpatient visit or a hospital admission (including associated emergency room or pre-admission services), plus your first follow-up outpatient visit to the Non-participating professional provider(s) who performed the service(s) during your hospital admission or emergency room visit.

  • When you receive care in a Preferred hospital from Non-participating professional providers such as a radiologist, anesthesiologist, certified registered nurse anesthetist (CRNA), pathologist, neonatologist or pediatric sub-specialist; and the professional providers are hospital-based or are specialists recruited from outside the hospital either without your knowledge and/or because they are needed to provide immediate medical or surgical expertise

  • When you receive care from Non-participating professional providers in a Preferred, Member or Non-member hospital as a result of a medical emergency or accidental injury (see pages 90-93 of the Service Benefit Brochure).

For more information, see Differences between our allowance and the bill in Section 4 of the Service Benefit Plan brochure. For more information about how we pay providers overseas, see page 31 and pages 121-122.

PrecertificationThe requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the services will be performed before being admitted to the hospital for inpatient care or within two business days following an emergency admission.
Preferred provider organization (PPO) arrangementAn arrangement between Local Plans and physicians, hospitals, healthcare institutions and other covered healthcare professionals (or for retail and Internet pharmacies, between pharmacies and CVS Caremark) to provide services to you at a reduced cost. The PPO provides you with an opportunity to reduce your out-of-pocket expenses for care by selecting your facilities and providers from among a specific group. PPO providers are available in most locations; using them whenever possible helps contain healthcare costs and reduces your out-of-pocket costs. The selection of PPO providers is solely the Local Plan's (or for pharmacies, CVS Caremark's) responsibility. We cannot guarantee that any specific provider will continue to participate in these PPO arrangements.
Prior approval

Written assurance that benefits will be provided by:

  • The Local Plan where the services will be performed
  • The Retail Pharmacy Program (for prescription drugs and supplies purchased through Preferred retail and Internet pharmacies) or the Mail Service Prescription Drug Program
  • The Blue Cross and Blue Shield Association Clinical Trials Information Unit for certain organ/tissue transplants we cover only in clinical trials. See Section 5.

For more information, see the benefit descriptions in Section 5 and How to get approval for . . . Other services in the Service Benefit Plan brochure. See Section 5(e) for special authorization requirements for mental health and substance abuse benefits.

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R

Routine services

Services that are not related to a specific illness, injury, set of symptoms or maternity care.

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S

Sound natural tooth

A tooth that is whole or properly restored (restoration with amalgams only); is without impairment, periodontal or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay or porcelain restoration or treated by endodontics, is not considered a sound natural tooth.

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T

Transplant period

A defined number of consecutive days associated with a covered organ/tissue transplant procedure.

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U

Us/We/Our

"Us," "we," and "our" refer to the Blue Cross and Blue Shield Service Benefit Plan and the local Blue Cross and Blue Shield Plans that administer it.

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Y

You/Your

"You" and "your" refer to the enrollee (the contract holder eligible for enrollment and coverage under the Federal Employees Health Benefits Program and enrolled in the Plan) and each covered family member.

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Page last updated: December 30, 2013

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