A prescription medication that BCN’s prescription drug program allows to be dispensed in quantities that exceed a 34-day supply when dispensed at a retail pharmacy.
See Master/Major Medical.
Systems and techniques used to help direct the utilization, cost and quality of health care services.
managed care organization
A health plan that manages health care delivery by having a defined network of select providers who contract to provide health care services to members. See also HMO. See also point of service. See also PPO.
A term used in advertising and marketing to emphasize that the Blues Traditional plan has cost-effective features.
Benefits required by law to be offered or provided by some or all health plans.
Master/Major Medical Coverage
The hospital, surgical and medical plans that supplement basic benefits by extending hospital days and providing additional benefits. Major Medical is used for national accounts, while Master Medical is used for local Michigan accounts.
maximum allowable cost
BCBSM’s prescription drug program feature, the MAC caps reimbursement for commonly dispensed drugs when there are generic products available.
The payment level BCBSM has established for a given procedure.
A federal program administered and operated by participating state and territorial governments that share the costs of providing medical benefits to eligible, disabled and low-income persons needing health care.
A general term for programs that promote high-quality, cost-effective health care through such activities as utilization management, quality management and risk management.
Blues guidelines determining the status of a service or technology as a standard of care or as investigational.
The process of determining the appropriateness of care or treatment. Usually part of claims adjudication.
The process of reviewing and possibly denying applications for coverage, based on health criteria.
The federal health insurance program for the aged, disabled and individuals with end stage renal disease established by Title XVIII of the Social Security Act of 1965, as amended.
- Original Medicare are services provided by the federal government as opposed to those provided by individual health plans through Part C.
- Part A covers inpatient hospital, home health, hospice, and limited skilled nursing facility services.
- Part B covers physician services, medical supplies and other outpatient treatment.
- Part C, now known as Medicare Advantage, provides coverage options that include PPOs, HMOs, point of service products, medical savings accounts and fee-for-service arrangements.
Sometimes referred to as Part C, these Medicare plans are administered by private insurance companies that have contracted with the federal government. These plans cover Medicare Parts A, B and sometimes D.
Medicare Blue USA®
A national network of Blue Cross and Blue Shield Medicare HMOs.
A benefit offered to members of a group who are 65 or older that pays the difference between the Medicare allowance and the group’s contract allowance for the same service.
Obsolete term. See also Medicare Supplemental.
Medicare + Choice
Pronounced Medicare plus choice. Now known as Medicare Advantage, this federally defined Medicare risk program identifies various Medicare coverage options that insurers and providers may offer.
Medicare secondary-payer laws
A series of laws defining when a health plan is required to pay its benefits before Medicare and including parts of many federal statutes such as the Tax Equity and Fiscal Responsibility Act, the Deficit Reduction Act, the Balanced Budget Act, the Omnibus Budget Reconciliation Act, the Consolidated Omnibus Budget Reconciliation Act and others.
The preferred term for coverage that pays many of the costs not covered by the federal program.
Used by the National Association of Insurance Commissioners and federal agencies to denote approved Medicare Supplemental coverage.
Any person eligible for health care services under the subscriber’s contract, which includes spouse and dependents.
The title of a rider that limits the amounts a member must pay for X-rays, lab work and EKGs.
metropolitan statistical area
Area with a population greater than 50,000, as defined by the Office of Management and Budget.
Michigan Health Benefits claim
Replaced by the HCFA-1500. The Michigan Health Benefits Review form is used for supplemental claims and status inquiries.
See HMO models.
A code that eliminates the need to provide additional documentation when submitting claims.
MSW certified social worker
See certified social worker.