These glossary terms and definitions are intended to be educational and may be different from the terms and definitions as defined in your plan documents.
Some of these terms also might not have exactly the same meaning when used in your policy or plan. In these instances, the policy or plan definition governs.
Glossary of Health Coverage and Medical Terms
A
Affordable Care Act
A law that helps more people get coverage of health insurance and makes sure insurance is fair and affordable.
Appeal
A request to change an adverse decision made by the organization. A member or the member’s authorized representative may appeal an adverse decision.
Authorized Individual
An individual who acts on behalf of another individual through consent or under applicable law. An organization may establish procedures for determining if an individual is authorized to act on behalf of a member. For urgent care decisions, an organization allows a health care practitioner with knowledge of the member’s medical condition (e.g., a treating practitioner) to act as the authorized representative.
B
Balanced Billing
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
D
Dependent
Someone, like a spouse, domestic partner, or child, who receives health care coverage through your insurance plan. For more details, please refer to your insurance plan.
E
Effective Date
The day your health coverage starts.
Emergency Medical Condition
A serious health problem that needs immediate care to prevent harm or death.
Emergency Medical Transportation
The way you are quickly brought to emergency care, such as by ambulance.
Emergency Services
Health care services, supplies or treatments furnished or required to screen, evaluate and treat an Emergency Medical Condition.
Exclusions
Health care services that your health insurance or plan doesn’t pay for or cover.
Expedited Appeal
An appeal of an adverse decision for coverage of urgent services.
Explanation of Benefits (EOB)
A paper or online summary that you receive after receiving medical services that shows what your health plan paid, what was not covered, and what you may owe after your visit.
External Appeal
A request for a third-party, independent review of an organization's adverse determination.
G
Grievance
A formal complaint you can send to your insurance carrier when you are unhappy with a service or decision.
Group / Client
A set of people, like employees at a company, who get health insurance coverage together.
H
Habilitation Services
Health care that helps you learn or improve skills for daily living, like walking or talking.
Health Care Exchange
A website that is regulated by the government where people can find health insurance coverage. They can use the site to learn more about the Marketplace, update their plan and compare plans. They can also use it to find local agents to help them.
Health Insurance
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Maintenance Organization (HMO)
An organized health care system that is accountable for financing and delivering comprehensive health services to an enrolled population, and for assessing access and ensuring quality and appropriate care. Services are rendered by practitioners affiliated with the health care system. To receive reimbursement, members must obtain all services from an affiliated practitioner and must comply with a defined authorization system.
Health Savings Account (HSA)
A tax-advantage account whose funds are used to pay for qualified medical expenses of the account holder or their spouse or dependents.
High Deductible Health Plan (HDHP)
A plan where you start paying out-of-pocket for care until you reach a threshold where your carrier takes on more of the costs. Some HDHPs can be paired with a Health Savings Account, pending thresholds that are set by the U.S. Internal Revenue Service.
Home Health Care
Health care you get at home from a nurse or health aide instead of going to a clinic or hospital.
Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization
Inpatient - A setting where patients are admitted for diagnostic, therapeutic (surgical and nonsurgical), rehabilitative or psychiatric services provided by or under the supervision of physicians on a 24-hour basis.
I
L
Limitations
Rules about what your health plan will or won't cover, like how many visits you get.
M
Medicaid
A joint state and federal program that provides health insurance to low income, including eligible children, pregnant women, seniors and individuals with disabilities.
Medical Necessary Health Care
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
N
O
Outpatient
A person treated as a registered Outpatient at a Hospital, clinic or in a Professional Health Care Provider’s office, who is not, at the time of treatment, a registered patient in a Hospital, Skilled Nursing Facility, Substance Use Facility, Psychiatric Care Facility or other Institutional Health Care Provider.
P
Physician Services
Activities or interventions in which individuals can participate to reach a specified health goal.
Plan
The agreement with BCBSND, Including the Subscriber's application, Identification Card, this Benefit Plan and any supplements, endorsements, attachments, addenda or amendments.
PPO Network
Preferred provider organization network. An organization that contracts with independent providers at a discount for services.
Pre-existing
A condition, disease, illness or injury for which the member receives medical advice or treatment six months or more prior to the effective date (for individuals/families) or enrollment date (for groups) of the member’s benefit plan
Preferred Provider
A doctor, nurse practitioner, physician assistant or health care facility that accepts your health plan. You usually pay less to see them.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Primary Care Physician
A group of Network Providers composed of Physicians, nurse practitioners, or Physician assistants who accept primary responsibility for the management of a Member's health care.
Prior-Authorization
The process of the Member or the Member’s representative notifying BCBSND of the Member's intent to receive services requiring authorization. The Member's Health Care Provider must provide
the necessary information to establish the requested services are Medically Appropriate and Necessary in order to receive benefits for such services. Eligibility for benefits for services requiring authorization is contingent upon compliance with the provisions of Section 3. Precertification/Prior-authorization does not guarantee payment of benefits.
R
S
Skilled Nursing Care
Medical care given by a nurse, often in a special care center or sometimes at home.
Special Enrollment Period (SEP)
A time outside of open enrollment when you can sign up for a health plan if you have a big life change, like getting married or losing coverage.
Specialist
A Health Care Provider who has completed advanced education and training, and practices or specializes in a specific area of medicine. Examples Include cardiologist, allergist, dermatologist, oncologist and urologist.
Subscriber
The person whose application for membership has been accepted, whose coverage is in force with BCBSND and in whose name the identification card is issued.
T
U
UCR (Usual, Customary and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Unique Member Identification Number
A number assigned by BCBSND and listed on the identification card that identifies the subscriber for administrative purposes.
Urgent Request
A request for medical care or services where application of the time frame for making routine or non-life threatening care determinations:
- Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or
- Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
- In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.
