The practice of billing a patient for the difference between the actual charge and what the provider receives from the Blues and the member copayment.
The amount a hospital actually spent to render care to Medicare patients in a previous time period.
The minimum set of health services that BCBSM offers through its Traditional plan.
A person eligible to receive Medicare benefits.
A health care service payable under a subscriber’s contract.
benefit dollar maximum, benefit maximum
The highest amount the Blues will pay for a specific benefit or class of benefits. A benefit may have an annual or a lifetime maximum.
Any provision that restricts coverage under the subscriber’s contract, regardless of medical necessity.
The health services that the Blues offer to a group or individual.
- Medicare term for a period of consecutive days that begins with the first day a patient enters a hospital or skilled nursing facility and ends when the patient has been out of the facility 60 days.
- General Motors term indicating when an enrollee is eligible to receive benefits, or denoting a period of time for specific coverage, such as hospice.
See anniversary date.
The most desirable or most effective level of activity, which becomes a standard to which other practices are compared.
The amount a health care provider bills a patient for a particular medical service or procedure.
The process used to determine which parent’s coverage pays first when a dependent child has health coverage through both parents. According to this coordination of benefits rule, the dependent child’s primary coverage is that of the parent whose birthday falls earlier in the calendar year.
A program that provides member savings and special offers on a variety of healthy products and services from national companies (see HealthyBlueXtras℠ for Michigan discount offerings).
A program that allows Blue Cross and Blue Shield Traditional, PPO and HMO members to receive the same health care benefits as their home plan while out of the plan’s area. A telecommunications system allows the interchange of provider pricing agreements and electronic claims among Blues plans.
Blue Care Network of Michigan
An independent, nonprofit subsidiary of Blue Cross Blue Shield of Michigan, this health maintenance organization combines the delivery and the financing of comprehensive health services.
An acronym (Broad-Level Utilization Evaluation and Control by Hospital, Inpatient, Physician and Procedure) representing the utilization criteria previously used by the Blues to evaluate provider services. BLUE CHIP criteria have been replaced by InterQual criteria. See also InterQual criteria.
Blue Choice® POS
A Blue Cross Blue Shield of Michigan managed care plan, this point of service product combines the features of an HMO and a PPO. If members choose providers outside a specified network, they pay deductibles and higher copayments. Blue Care Network manages the POS provider network.
Blue Cross and Blue Shield Association®
An association of independent Blue Cross and Blue Shield plans that licenses individual plans to offer health benefits under the brand name and logo. The Association establishes uniform financial standards but does not guarantee an individual plan’s financial obligations.
Blue Cross Blue Shield of Michigan
A nonprofit health care corporation organized under Michigan law and an independent licensee of the Blue Cross and Blue Shield Association.
A 24-hour information line that puts Blues members in touch with registered nurses and an audio library of health information.
Blue Preferred® PPO
A BCBSM PPO plan that reimburses covered services at 100 percent when members use in-network providers and requires member copayments when services are provided outside the network without a referral from a network provider.
Blue Preferred Plus
A BCBSM PPO designed specifically for automotive groups. See also Blue Preferred PPO.
A physician who has passed a written and oral examination given by a medical specialty board.
A physician who is eligible to take a specialty board examination by virtue of having graduated from an approved medical school, having completed a specific training program and having practiced for a period of time.
Products that carry the Blue Cross and Blue Shield name, such as Blue Choice.
The setting of an inclusive package price for all the medical services required for a specific procedure (for example, maternity care). The bundled price generally includes professional and facility services.