Method of payment for health services in which a health care provider is paid a fixed amount for each person served regardless of the actual services provided.
A Blues subscriber.
See case management.
A provision in some major medical plans that allows individuals to apply expenses incurred in the last quarter of a calendar year to the following year’s deductible.
Specific benefits administered separately from the rest of an organization’s health insurance package, such as mental health, dental, vision and prescription drugs.
A program of individual planning and care for seriously ill people, with a case or care manager working with patient and physician to ensure that all appropriate care and appliances are provided and paid for, including specific services that may not be covered by the subscriber’s contract.
The different types of patients that a provider treats, whose age, gender or diagnosis directly influences the scope of services provided.
catastrophic health insurance
Protection against the high cost of treating severe or lengthy illnesses or disabilities. Generally such policies cover all, or a specified percentage of, medical expenses above an amount that is the responsibility of another insurance policy. As well, there is generally a ceiling on the amount paid out.
The American Dental Association manual, Current Dental Terminology, that lists descriptive terms and identifying codes for reporting dental services and procedures.
Central Review Organization
BCBSM’s medical staff (physicians and nurses) who review requests for predeterminations, recertifications and member appeals. The group determines if a request is appropriate for the setting and assigns length of stay according to established medical criteria.
Centers for Medicare and Medicaid Services
A division of the federal Department of Health and Human Services that administers Medicare and oversees each state’s administration of Medicaid. Formerly called the Health Care Financing Administration.
Centers of Excellence
A network of select hospitals whose specialty programs and staffs have met the Blues’ quality criteria and also may provide added value to managed care customers by offering competitive prices on certain high-risk specialty procedures.
A legal document approved by the state insurance bureau, that lists the terms, benefits and limitations of the health care coverage the Blues provide in all lines of business, including any riders that amend this certificate.
certificate of creditable coverage
A document that proves an individual previously had health care coverage. It can be applied to reduce or eliminate any preexisting exclusion period that might otherwise apply when someone changes jobs.
certificate of need
A document issued by a state governmental body to an organization that is proposing to build or modify a health facility, offer a new or different health service or purchase a major piece of equipment.
The process by which an agency or association evaluates and recognizes an individual, institution or educational program as meeting predetermined standards. The term is synonymous with accreditation, except that certification is usually applied to individuals and accreditation to institutions. See also accreditation.
certified nurse midwife
A registered nurse with no less than one-and-a-half years of post-nursing school education in midwifery who is certified by the American College of Nurse Midwives to provide well-woman gynecological and low-risk obstetrical care.
certified nurse practitioner
A specialty nurse licensed in Michigan to practice a specific discipline who is also a Michigan-licensed registered nurse with a degree from an approved course of nurse-practitioner education and certified by a national nursing organization and the state Board of Nursing.
certified registered nurse anesthetist
A Michigan-licensed, registered professional nurse who has graduated from an approved course of nurse-practitioner education, is certified by a national nursing organization and the Michigan Board of Nursing, and has the requisite additional hours of training in the administration of anesthesia to qualify for state certification and to function as an anesthetist under the direction of a physician.
certified social worker
The preferred term for a master’s-level social worker who specializes in the treatment of mental disorders. Certification from the Michigan Department of Consumer and Industry Services implies that these individuals have an MSW degree and two years’ post-graduate clinical practice.
Civilian Health and Medical Program of the Uniformed Service that provides medical coverage for dependents and families of active-duty and retired military personnel.
A request for retrospective payment by a member or by a health care provider on the member’s behalf for health care services or devices supplied.
Blues system that identifies procedure unbundling, incidental procedures and mutually exclusive procedures.
claim control number
A 10-digit number assigned to each claim for hospital admission processed by BCBSM.
The methods by which health care service claims are professionally examined before any reimbursement is made to validate the medical appropriateness of the services provided and to be sure the cost of the service is not excessive.
claims tracking system
A feature of the HART (Hospital Access and Response Terminal) system that allows providers to locate and monitor claims from the day they are received by BCBSM until they are paid or rejected. See also HART.
clinical care standards
Blues criteria indicating expected levels of performance regarding care management and patient care outcomes.
Measures of performance showing patterns of care among defined populations, as the result of a certain program of care (for example, mental health) in facilities and among clinicians.
clinical nurse specialist
A registered nurse who becomes expert in a defined area of knowledge, through study and supervised practice at the graduate level, and practices in a selected clinical area of nursing.
A treatment regimen that describes the treatment and intervention activities to be performed for a specific illness.
clinical practice guidelines
Protocols based on the most current scientific findings, clinical expertise and community standards of practice that assist the practitioner in determining appropriate health care for specific situations.
See fully licensed psychologist.
clinical review criteria
Guidelines used to evaluate medical necessity and appropriateness of care.
clinical social worker
See certified social worker.
A centrally based group of salaried physicians, such as BCN’s Health Centers, that provides health services to an HMO’s members. Also referred to as a group model or staff model.
Federal laws applying to groups of 20 or more, the Consolidated Omnibus Budget Reconciliation Act offers extended coverage for enrollees and family members after group coverage would normally end.
Term used by Centers for Medicare and Medicaid Services to mean the fixed amount or percentage of the Medicare-approved amount that a Medicare beneficiary must pay the provider for a covered service. Same as copayment. See also copayment.
BCBSM’s PPO benefit that includes a wide range of preventive services as basic benefits payable directly to TRUST-network physicians. See also TRUST.
A system of calculating health insurance premiums based on the average cost of providing medical services to all people in a geographic area without adjusting for an individual’s medical history. Also known as area rating.
Comprehensive Major Medical
A plan that covers hospital and medical-surgical services and other benefits, characterized by a deductible, coinsurance and maximum benefits.
A review of patient care while the patient is still in the hospital to determine the medical necessity for the treatment and the length of stay. See also admission certification.
An amount of cash and other assets that the state insurance bureau determines the Blues must hold in reserve to ensure financial solvency and to cover claim payments in the event of extreme underwriting losses.
continuity of care
Continuation of care by a primary care physician or specialist even after the doctor’s relationship with BCN ends.
continuum of care
A range of health-related services provided to an individual or group, which may reflect treatment rendered during a single hospitalization or care for multiple conditions over a lifetime. The continuum of care provides a basis for analyzing quality, cost and utilization over the long term.
The legal agreement that exists between Blue Cross and the subscriber, consisting of the certificate, the signed application for coverage and the Blue Cross Blue Shield of Michigan or Blue Care Network identification card.
A nine-digit number on the Blues identification card, usually the same as the subscriber’s Social Security number.
The 12-month period beginning on the effective date of a group’s coverage.
A local Blue Cross or Blue Shield plan that is responsible for administering a national account.
The right of eligible group members to convert to individual policies with no health statement requirements when their group insurance ends. Benefits under the new policy may be different from those under the group policy. See also group conversion.
coordinated care management
Voluntary disease management program for patients with chronic conditions such as heart disease, asthma and diabetes that uses care managers who work with the patient, the physician and other health care providers to manage the condition and improve the patient’s health.
coordination of benefits
A program that coordinates the subscriber’s health benefits when the person is covered under more than one group health plan.
A fixed amount or percentage of the Blues approved amount that the member must pay the provider for a covered service. See also coinsurance.
Procedures used primarily for improving appearance rather than for treating an illness or disease; generally not covered by the Blues.
See coordination of benefits.
See cost management.
Preferred term for programs that monitor the appropriateness of health care through utilization review, coordination of benefits, predetermination of benefits and antifraud efforts. This general term includes cost avoidance programs that prevent unnecessary expenditures and cost savings programs that recover dollars paid inappropriately.
The total scope of benefits under a subscriber’s certificate.
Those services, drugs or supplies identified as payable in the subscriber’s certificate that are determined to be medically necessary.
The American Medical Association manual, Current Procedural Terminology, that lists descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.
The process of licensing, accrediting and certifying health care providers prior to allowing them to participate in a provider critical pathway. See clinical pathway.
Care provided by people without professional skills or training to help a patient with activities of daily living.