Terms and definitions may not apply to all benefit plans. Please contact Member Services for plan-specific information.
A clinic or group of independent physicians chosen by the members on the benefit plan from which they will receive their health care services. This may also be referred to as your network.
The maximum amount payable to a health care provider for a procedure or service. When seeking services from a Blue Cross Blue Shield of North Dakota (BCBSND) participating provider, the allowed charge (and any cost-sharing amounts) is accepted as payment in full for covered services.
All hospital services for a patient other than room and board and professional services. Laboratory tests and X-rays are examples of ancillary services.
A network provider requests an authorization for the member to receive care from a provider who is not part of the member's chosen network. This request is reviewed by the network Medical Director, and then forwarded to a BCBSND Medical Director for review. Approved referrals are not granted to accommodate personal preference, family convenience or other non-medical reasons.
A benefit period is one calendar year. It begins on January 1 of each year and ends on December 31 of the same year.
The BlueCard program allows you the freedom to choose a Blue Cross Blue Shield provider anywhere in the United States—an important advantage if you receive services outside North Dakota. More than 85 percent of all hospitals and health care providers nationwide participate with a Blue Cross Blue Shield plan.
Brand Name Drug
A brand name drug is a prescription drug with the registered trademark name given to the drug by its manufacturer, labeler or distributor.
Information provided by a health care provider or a member to establish that services were provided. Providers typically submit the claim to BCBSND on your behalf.
- Professional claims are claims for services provided by a doctor, therapist, etc. including major medical prescription claims.
- Hospital claims are claims for services provided in an Emergency Room or Hospital setting.
- Prescription claims are claims for prescription drugs that are processed electronically through RxDakota. Major Medical prescription drug claims are processed as a Professional claim.
- Dental Claims are claims for services provided by a dentist, orthodontist, etc.
- Vision Claims are claims for services provided by an optometrist, ophthalmologist, etc.
A claim number is the number assigned to a claim for services when it is entered into the claims processing system.
"Processed claims" are claims that have successfully processed through our system.
"In Process claims" are claims that haven't completed the processing cycle. This status does not apply to Prescription claims.
A percentage of the allowed charge for covered services that is a member's responsibility. Some medical groups may require that the coinsurance amount be paid at the time of service.
The limit set on the total coinsurance amount you must pay during the calendar year.
A specified dollar amount payable by the member for certain covered services. Some medical groups may require that the copayment amount be paid at the time of service. Generally copayment amounts do not apply toward the deductible or coinsurance maximum amounts.
The dollar amount a Member is responsible for paying when Covered Services are received from a Health Care Provider. Cost Sharing Amounts include Deductible, Coinsurance and Copayment amounts.
Medically Appropriate and Necessary services and supplies for which benefits are available when provided by a Health Care Provider.
A specified dollar amount payable by the member for certain covered services received during the benefit period. Some medical groups may require that the deductible amount be paid at the time of service.
Duplicate Explanation of Benefits (EOB)
A duplicate Explanation of Benefits (EOB) is an almost identical reproduction of the original EOB you received. The year-to-date cost-sharing status will not be found on a duplicate EOB.
Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a document sent to the member by BCBSND after a claim for services has been processed. It includes the member's name, claim number, type of service, health care provider, date of service, charges submitted for the services, amounts covered by this benefit plan, non-covered services, cost-sharing amounts and the amount that is the plan holder's responsibility. This form should be carefully reviewed and kept with other important records.
A formulary drug is a brand name or generic prescription medication or drug that is safe, therapeutically effective, high quality and cost effective, as determined by a committee of physicians and pharmacists. A listing of these drugs is available to you online, under Member Support, Drug Formulary List.
The maximum dollar amount that is allowed on glasses frames. Charges in excess of the frame allowance will be the member's responsibility. The frame and/or lens allowances may be applied toward contact lenses instead of glasses.
A generic drug conveys the established or official chemical name of a drug, product or medicine.
Identification Card (ID card)
A card issued by BCBSND to the plan holder as evidence of membership. The card includes the plan holder's name, benefit plan number and type of coverage.
Services you receive from a provider within your chosen network or affiliation. You and your family must obtain all medical services from this network for an entire year, beginning on your group's anniversary date.
A separate copayment per inpatient day for hospital services.
The maximum dollar amount that is allowed on lenses. This amount is accepted as payment in full when services are rendered by a participating North Dakota Vision Service, Inc. provider. Charges for specialty lenses or procedures are not covered. This includes, but is not limited to, the following examples: oversized lenses, polycarbonate lenses, scratch coating and UV coating. The frame and lens allowances may be applied toward contact lenses instead of glasses.
The total dollar amount for covered services an eligible member may receive during a lifetime while enrolled under a benefit plan underwritten or administered by BCBSND.
Maintenance drugs are prescription medications that are allowed to be dispensed in amounts up to a 100-day supply.
Medically Appropriate and Necessary
A term used to describe those services, supplies or treatments provided by a health care provider to treat an illness or injury that satisfy the following criteria as determined by BCBSND:
- The services, supplies or treatments are medically required and appropriate for the diagnosis and treatment of a member's illness or injury.
- The services, supplies or treatment are consistent with professionally recognized standards of health care.
- The services, supplies or treatments do not involve costs that are excessive in comparison with alternative services that would be effective for diagnosis and treatment of the member's illness or injury.
The plan holder and, if single plus dependent, two party or family coverage is in force, the plan holder's eligible dependents.
Member Rebate Account (MRA)
Blue Cross Blue Shield of North Dakota (BCBSND) receives retrospective discount payments, referred to in the pharmaceutical industry as rebates, from some drug manufacturers for certain medications. A portion of these rebates may be passed directly to you because you pay part of the prescription drugs costs under your health benefit plan.
BCBSND has established a Member Rebate Account (MRA) in your name. BCBSND receives the rebate discount from the manufacturers typically 12 to 15 months after your purchase. Each quarter, BCBSND calculates your portion of any applicable rebates for covered prescription drugs and transfers it into your specific MRA.
Your portion of the rebate is based on a percentage of the out-of-pocket expenses, less any copayments you paid. However, please note that not all prescription drugs are eligible for rebates and rebate percentages can fluctuate from year to year. Once your portion has been transferred into your MRA, you will automatically receive a discount the next time you purchase a prescription drug.
A clinic or group of independent physicians. They have agreed to accept BCBSND- negotiated rates as payment in full, less cost-sharing amounts. See also In-Network and Out-of-Network.
A non-formulary drug is any drug not on the formulary drug list. Also see Formulary Drug.
Non-maintenance drugs are prescription medications that are allowed to be dispensed in amounts up to a 34-day supply.
Online Explanation of Benefits (EOB)
An Online Explanation of Benefits (EOB) is a document that members can print from Claim Detail on the website after a claim for services has been processed. It includes the member's name, claim number, type of service, health care provider, date of service, charges submitted for the services, amounts covered by this Benefit Plan, non-covered services, cost-sharing amounts and the amount that is the plan holder's responsibility.
Services you receive from a provider outside your chosen network. Higher cost share will apply to out-of-network services. A member can avoid out-of-network costs by obtaining an approved referral.
The total deductible and coinsurance amounts for certain covered services that are the member's responsibility during a benefit period. When the out-of-pocket maximum amount is met, the benefit plan will pay 100 percent of the allowed charge for covered services, less copayment amounts incurred during the remainder of the benefit period. Copayment amounts do not apply toward the out-of-pocket maximum amount.
Participating Health Care Provider
A health care provider who has entered into an agreement with Blue Cross Blue Shield of North Dakota to accept established negotiated rates as payment in full for covered services.
Participating Health Care Providers will submit claims for such members directly to BCBSND.
Per-Admission Deductible (Personal Choice only)
The per-admission deductible applies to inpatient admissions only and is assessed each time you or an eligible member of your family is admitted into a hospital, skilled nursing facility or other institutional health care provider.
If you choose to receive services from a nonparticipating BCBSND provider, you must have the provider notify BCBSND prior to receiving certain services. If you fail to obtain preauthorization before you receive care, benefits may be reduced or denied. Preauthorization does not mean that payment of benefits is guaranteed.
A condition, disease, illness or injury for which you receive medical advice or treatment six months or more prior to the effective date (for individuals/families) or enrollment date (for groups) of your benefit plan.
A process under which the member must provide information substantiating the necessity of specified services to BCBSND prior to receiving care. BCBSND reserves the right to deny benefits if you do not obtain prior approval.
A hospital, clinic, physician or other facility that provides health care services.
The service date is the date on which services were rendered.
On My Claims History page, the claims will be displayed for any services matching the selected criteria beginning with the service date and continuing through the current date. Searches are limited to the last 18 months.
For example, if you select January 2011, the system will display all claims for services between January 01, 2011 and today's date.
A single plan is coverage that includes only one person (the subscriber) on the plan.
A specified period of time the member is not entitled to benefits for specified services, beginning on the individual member's effective or enrollment date under the benefit plan. For additional information about waiting periods, contact Member Services.