Blue Cross Blue Shield Michigan’s automated telephone system, the Provider Automated Response System, informs professional providers about members, including eligibility, benefits, copays, deductibles and the benefit year.
The term used by the medical and insurance industry for network. See also network.
A program that provides less than 24-hour care (usually during the day) for mental health care, rehabilitative care or other services, often for patients in transition from full-time inpatient care to outpatient care.
Participating Hospital Agreement
The contract between a hospital and Blue Cross Blue Shield of Michigan, the PHA defines the legal rights and obligations of the parties.
A participant in the Blue Cross and Blue Shield Association that uses our plan to process claims for its members or processes claims for ours.
A facility or other provider that contracts with the Blues to provide care or services to members under specific reimbursement terms.
pay and pursue
A coordination-of-benefits approach to determine primary and secondary liability after claims are paid. Replaced by a pursue-and-pay approach. See also pursue and pay.
Classification system that groups providers for comparison purposes.
Evaluation by practicing physicians or other professionals of the effectiveness and efficiency of services ordered or performed by colleagues.
A claim that has been received and assigned an interim status until it is paid or rejected.
Decision by nonparticipating providers to accept our payment as full reimbursement for a particular claim with no further charge to the member.
Negotiated daily payment for facility inpatient services.
Measures used to rate the performance of a health plan or its providers, including mortality rates, costs, rates of specific procedures, rates of hospitalization for preventable diseases or patient satisfaction.
BCN’s HMO coverage for individuals who are not eligible for group membership.
Term used in BCBSM certificates to reference medical doctors, doctors of osteopathy, doctors of podiatric medicine, doctors of chiropractic, fully licensed psychologists, doctors of dental surgery and doctors of medicine in dentistry.
Individual who has received at least two years of training to provide diagnostic, therapeutic and preventive health care services as delegated by a physician.
physician hospital organization
A legal entity formed and owned by one or more hospital and physician groups that serves as a negotiating, contracting and marketing unit.
An independent Blue Cross or Blue Shield organization that operates in a given area of the country.
point of service
A managed care plan in which the members choose providers at the point of service — in or out of network — with copayment or deductibles determined by their choice.
A written contract or agreement between a commercial insurance company and the insured person or policyholder that includes all amendments and a copy of the application, if attached. See also subscriber contract.
Government requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans and ensures that individuals changing jobs are guaranteed coverage with their new plans.
A health care network of primary care doctors, specialists, hospitals and other providers of care, the preferred provider organization focuses on delivering cost-effective, quality patient care. Members save money when they use network providers and avoid a sanction for out-of-network services. BCBSM’s Blue Preferred® and Community Blue℠ benefit plans use the TRUST PPO network of doctors.
A document that used algorithms (if/then statements or questions) to guide evaluation or management of a clinical condition or to review the appropriateness of clinical interventions.
The practice of reviewing an inpatient admission before the patient enters the hospital to ensure that the admission is medically necessary. See also admission certification.
The Michigan Insurance Bureau’s preferred term for a combination of precertification and preauthorization procedures for certain surgical procedures such as organ transplants. At the bureau’s request, this term is used in certificates covering organ transplants.
A voluntary process that allows physicians and other professional providers to determine, before treating a patient, if BCBSM will cover the cost of a proposed service.
BCBSM’s review of a patient’s symptoms and proposed treatment to determine, in advance, whether they meet nationally recognized clinical screening criteria for inpatient treatment. The process is also used to review selected outpatient procedures, such as MRIs.
Term used only by automotive customers for preauthorization and precertification.
A condition for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment period after the effective date. This provision is subject to statutory limitations.
preferred provider organization
Preferred Rx Plan
A prescription drug plan that provides an open-access network of pharmacies.
A process by which participating hospitals notify BCBSM of a member’s inpatient admission, allowing for the identification of cases that may need care management or other health care services.
Preferred term for the range of fees usually charged by physicians with similar skills and experience for the same service within the same geographic area.
Covered services provided for health maintenance — such as routine health exams and tests, well-baby and well-child care and immunizations — based on a member’s age and gender.
Medical practice based on direct contact with the patient without referral from another physician.
primary care physician (PCP)
A physician a member chooses to provide and coordinate all of their medical health care, including specialty and hospital care, for the Blues’ HMO or Point-of-Service (POS) plans. The primary care physician is licensed in the state of Michigan in one of the following medical fields: internal medicine, family practice, general practice, pediatrics, and internal medicine/pediatrics.
The carrier responsible for providing benefits before any other insurer makes payment.
The medical condition that is the primary reason for a patient’s admission to the hospital.
An agreement between the patient and a nonparticipating physician before any service is billed, stating that the patient will be responsible for paying any amount over BCBSM’s payment for approved services.
A prescription drug plan requirement for prescribers to obtain authorization from the health plan before prescribing certain drugs.
The period that an individual must wait after beginning a job before becoming eligible for group insurance coverage.
A series of numeric or alphanumeric characters and corresponding descriptions for each medical service.
Type or class of coverage — Traditional, HMO, PPO and point of service — as presented to the market by the Blues sales force and independent agents.
The portion of a charge for services performed in a hospital that is allocated to the professional services of a physician, as distinct from a technical facility component.
A doctor (of medicine, osteopathy or podiatric medicine) or other practitioner (chiropractor, fully licensed psychologist or dentist) who is licensed, certified or approved by the appropriate agency to render covered services in a state.
professional service coverage code
The characters of the coverage code on the member’s identification card that indicate coverage for services additional to hospital and medical-surgical.
Groupings of tests that laboratories or physicians design to simplify orders for lab services that are frequently performed together.
prospective payment system
A payment methodology that establishes rates and prices before services are rendered and costs incurred.
An artificial device that replaces all or part of a body part, or all or part of the functions of a permanently disabled or poorly functioning body organ. See also orthotic appliance.
Person or facility providing services or supplies related to medical care.
pursue and pay
A coordination of benefits approach to determine primary and secondary liability before claims are paid. Also called cost avoidance.