A surgical procedure that is not associated with an emergency or maternity condition and can be scheduled for the convenience of the member or surgeon.
The date on which an individual becomes entitled to benefits under an insurance plan.
emergency first aid
The initial exam and treatment of conditions resulting from accidental injury.
Used in managed care to define a face-to-face meeting between a professional provider and a member during which health care services or supplies are provided but no claim is generated. Encounters are included in the capitation agreement with the provider.
Another term for member; preferred by automotive groups and by Medicare.
The period of time when individuals in a group may enroll for health benefits.
See explanation of benefits.
See explanation of Medicare benefits.
episode of care
A defined period of illness that has a definite start and end date.
A federal law, the Employment Retirement Income Security Act of 1974 regulates employee retirement and welfare plans.
A set of procedures, pre-appraised resources and information tools that help practitioners apply evidence from research to the care of individual patients.
Product name used by Blues’ automotive groups and others for supplemental coverage that brings Medicare beneficiaries in their group plans to the same level of benefits as active employees.
A method of determining a group’s premium rates based wholly or partly on the group’s own claims experience.
explanation of benefits
A statement to Blues subscribers or members that details what services have been paid and what may be owed.
explanation of medicare benefits
A statement to beneficiaries that details what services Medicare has paid and what they may owe.
Long-term care, especially after hospitalization, requiring inpatient stay in a facility such as a nursing home or rehabilitation facility.