Managed care plan that allows members to see participating providers, usually specialists, without a referral from a primary care doctor.
- A period during which subscribers in a health plan can change their health coverage.
- A period when uninsured individuals can obtain coverage without presenting health statements.
oral and maxillofacial surgeon
A licensed dentist who has advanced training and demonstrated competency through examination or other evaluative processes to perform surgery on the lower jaw and dental structure. See also dentist.
A device, such as a leg brace, worn outside the body to correct a body defect of form or function. See also prosthetic appliance.
Coverage provided for individuals who are not associated with any kind of group.
System used to track clinical treatment and responses to that treatment.
Collection and analysis of medical performances based on certain specifications.
Services or costs that differ substantially from the standard established in a statistical profile of cost or usage.
Coverage available to individuals living or traveling outside a health plan’s service area.
The dollar amount or percentage of the Blues-approved amount that the member must pay under a PPO, POS or other managed care plan when going to a non-network provider without an appropriate referral. Same as sanction.
Services performed by a provider who has not signed a contract with the member’s health plan to be part of a provider network.
The highest dollar amount a member or family must pay in combined copayments and deductibles during any given year.
See ambulatory surgery.
Service provided by a consultant provider, usually a specialist who is outside the plan’s network.