The amount deducted from the Blues’ usual payment if certain program guidelines are not followed by the member or provider.
See prevailing charge.
Opinions obtained from more than one provider as to the best course of treatment, usually with regard to surgery. Some groups require second opinions for certain procedures.
See Medicare secondary payer.
A correlation between the health plan and the characteristics of the employees who use it, as related to their health, provider preferences and tendency to use health services. See also adverse selection.
The preferred term for a group health plan in which the employer assumes the risk for (or underwrites) the cost of all covered health care services.
See self-funded plan.
- The geographic boundaries established for HMO care.
- The geographic area a BCBS plan is licensed to serve.
Financing system in which the government acts as the only insurer and sets rates for providers.
skilled nursing facility
A freestanding facility or part of a hospital that is licensed to provide convalescent and short-term illness care with continuous nursing and other health care services provided by or under the supervision of a physician and a registered nurse.
standard of care
A predefined process of care that the patient can expect from a health care encounter based on current scientific knowledge and clinical expertise.
standard of practice
An acceptable level of performance or an expectation for professional intervention, formulated by professional organizations based upon current scientific knowledge and clinical expertise.
A prescription drug plan requirement for prescribers to use certain lower-cost drugs before trying others used for the same treatment.
The additional insurance a self-funded group may purchase to limit the total amount it must pay for health care claims in a given year as protection against unanticipated high costs due to catastrophic illness or accidents.
A level of care for patients not requiring the intensity of services of a hospital.
The right to recover payment when another person, insurance company or organization may be legally obligated to pay for health care services that the Blues have already paid; for example, in the case of a court judgment.
The person who signs and submits the application for coverage and whose name appears on the ID card. See also cardholder.
The legal agreement that exists between the Blues and the subscriber, consisting of three documents: the certificate, the signed application for coverage and the identification card.
Any cost a subscriber is responsible for, such as deductibles and copayments.