Your plan for better healthSM1
Search
A  | B  | C  | D  | E  | F  | G  | H  | I  | L  | M  | N  | O  | P  | Q  | R  | S  | T  | U  | V  | W  | Y 

Here are definitions of some of the terms that are used throughout the site.

 

ABMS (American Board of Medical Specialties): The ABMS is the umbrella organization under which the 24 certifying medical boards function in the United States. ABMS's main purpose is to coordinate information regarding medical specialties and certification in medicine, and to disseminate such information to the public, government and the medical profession.

Abdominoplasty (Tummy Tuck): Abdominoplasty is surgery to tighten abdominal muscles and skin, and is often performed after multiple pregnancies or weight loss. A "mini" tummy tuck addresses muscle weakness and skin laxity below the navel. The amount of muscle and skin weakening will determine whether a full or modified (mini) abdominoplasty is warranted.

Acceptance of New Patients : Designates who the physician is accepting for initial appointments. How information is collected: Information is indicated by the provider at upon initial contracting or renewal of contract. When is the information updated: When the provider updates BCBSNC to a change in status. Limitations: Reliance on provider updates

Appointments available for current patients only: This provider is only accepting current patients or previous patients with a still-active chart. Please call the provider for verification. How information is collected: Information is indicated by the provider at upon initial contracting or renewal of contract. When is the information updated: When the provider updates BCBSNC to a change in status.

Accreditation: The formal evaluation of an organization according to accepted criteria or standards. Accreditation may be done by a professional society, a non-governmental body, or a governmental agency. NCQA accreditation is a nationally recognized evaluation that purchasers, regulators, and consumers can use to assess managed care plans. How information is collected: As noted on Application and Copy of Accreditation certificate with effective dates. When is the information updated: Time of recredentialing or when notified by the Facility.

Actual charge: The amount a doctor or other healthcare provider actually bills a patient. The actual charge may be different from the allowable charge. This means your health plan may only cover a portion of what your doctor charges you and you will be asked to pay the difference. For example, your doctor may charge $40 for an office visit - this is the actual charge. However, your health plan may only allow for $30 visit. Therefore, you would be required to pay the difference of $10.

Acupressure: A massage technique which stimulates pressure points on the surface of the body to promote circulation, derived from ancient Chinese methods. See also Therapeutic Massage.

Acupuncture: A technique of oriental medicine performed only by licensed health care providers. Fine needles are inserted into the body at specific points to induce anesthesia, relieve pain, or to treat other various disorders.

Adjudication: The process of determining the reimbursement applicable to a particular claim.

Aesthetic Surgery: See Cosmetic Surgery

Aesthetician: An aesthetician is a non-medical practitioner who specializes in the education, preventive care and treatment of the skin, by offering non-invasive treatments, such as facials, light chemical peels, exfoliation, make-up application and other skin care therapies.

Agent: A person or organization who is authorized by an insurer to act on its behalf to negotiate, sell, and service managed care contracts.

Alexander Technique: A somatic education method that develops and maintains the alignment of the head, neck and back in order to reduce unnecessary strains on the body, improve posture and overall health.

Allergy Treatment: Allergy testing, allergy immunotherapy, and allergy injection services indicated by standard medical practice.

Allowable Charge: The maximum fee that a health plan will reimburse a provider for a given service.

Allowed Amount: The charge that BCBSNC determines is reasonable for covered services provided to a member. This may be established in accordance with an agreement between the provider and BCBSNC.

Alternative medicine practitioner: A professional who practices acupuncture; bodywork; chiropractic; cooking instruction; fitness instruction; massage; mind/body relaxation; nutritional counseling; somatic education; Qi Gong; Tai Chi; or Yoga who may or may not be licensed or certified in the state of practice. Alternative medicine services are not a covered benefit, but BCBSNC members get discounts through contracted practitioners.

Alternative Medicine: Alternative medicine includes a variety of therapies that work to increase wellness, prevent illness and address existing symptoms and conditions. Increasingly, many medical professionals regard alternative medicine as complementary to conventional medicine. In fact, it is sometimes referred to as complementary and alternative medicine

Ambulatory Care: Medical services that are provided on an outpatient (non-hospitalized) basis, including the office setting. Generally synonymous with outpatient; however, some outpatient services may be excluded.

Ambulatory Surgery: See Outpatient Surgery.

Ambulatory Surgery Center: A non-hospital facility with an organized staff of doctors, which is licensed or certified in the state where located, and which:

  • Has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis.
  • Provides nursing services and treatment by or under the supervision of doctors whenever the patient is in the facility.
  • Does not provide inpatient accommodations.
  • Is no other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other provider.

Ancillary Services: Facility services exclusive of room and board, such as supplies and laboratory tests provided in the following settings: Homecare, Durable Medical Equipment (DME), Ambulatory Surgical Centers (ASC), Home Infusion, Hospice, Skilled Nursing Facility (SNF), Mobile Lithotripsy, Sleep Centers, and Dialysis.

Antioxidant: Substances that render free radicals incapable of doing damage. Some of the most important antioxidants are Vitamins C and E, and Beta Carotene.

Appeals: A process used by a patient to request the health plan reconsider a previous authorization or claim decision.

Arm Lift (Brachioplasty): Brachioplasty is a procedure also known as "arm tightening" to eliminate excess skin from the upper arm. This condition can occur as a result of age or significant weight loss. Although the arm contour is greatly improved, this procedure leaves a permanent and noticeable scar. The scarring is a significant factor when considering this procedure.

Astigmatism: Results from an abnormally shaped cornea. Light rays are refracted unequally causing images viewed at most distances to appear ghost-like or blurry.

Authorization: See Pre-Authorization.

Authorized Signatory: The person who has legal authority to enter into contracts on behalf of the provider group identified.

Average Cost: Total doctor and/or hospital charges divided by total cases.

Average Hospital Days: Total number of days divided by the number of admissions.

Back to top

 

Base HSA contribution: The lesser of your deductible or the maximum HSA contribution allowed by law.

BCBSNC Provider Number: The BCBSNC group or entity provider number under which claims are filed to BCBSNC.

Beneficiary: A person who is eligible to receive insurance benefits.

Benefit: Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured or, on his behalf, to the medical provider. Benefit design includes the types of benefits offered, limits e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), subscriber incentives to use network providers.

Benefit Period: The specified period of time during which charges for covered services provided to a member must be incurred in order to be eligible for payment. A typical benefits period is a calendar year.

Beta Carotene: Member of the family of compounds called "carotenoids," which give orange and yellow fruits and vegetables their characteristic color. It is one of several forms of yellow pigments that the body can convert into Vitamin A. Beta Carotene is also found in dark green leafy vegetables.

Billed Charges: Total hospital and/ or doctor charges billed by the provider. Charges represent the gross billed or retail price of services. Charges do not necessarily represent the amount paid by the member or the amount collected by the provider.

Biofeedback: A training technique to consciously regulate normal body functions such as heart rate, breathing, brain activity levels and body temperature. This technique helps to change physical responses to stress as well as enhance overall health. Training is guided by both a trained practitioner and simple electronic devices that monitor body functions and provide feedback.

Birthing Center: A facility that allows mothers to give birth in a home-like setting.

Blepharoplasty (Eyelid Surgery): Blepharoplasty is the procedure to remove excess skin from the upper lids and to remove fat, or reposition fat from the lower lids. Upper and lower lid surgery can be performed together or separately. There are several techniques that doctors use when dealing with lower eyelid surgery. It is important to understand the varying surgical options.

BlueCard Program: A BCBSA program that links participating health care providers and the independent Blue Cross and Blue Shield Plans across the country and abroad with a single electronic process for professional, outpatient and inpatient claims processing and reimbursement. The program allows members obtaining health care services while out of town to receive the same benefits of their Blue Cross plan and access out-of-town providers' savings. In most cases, providers bill claims directly to their local Plans without requiring up-front payment from the member.

Board Certified Surgeon: A board certified surgeon is someone who has completed the required course of study, including an accredited residency in a particular field and has successfully passed the examination given by the certifying board.

Board Certification With Expiration Date: Designates a physician who has completed training and passed qualifying exams in his/her specialty area. How information is collected: Via a verification service (boardcertifieddocs.com) approved by ABMS. When is the information updated: At time or recredentialing or if notified by the provider and subsequent verification. Limitations: Certification may change in the interim between credentialing cycles.

Botox: Botox is most often used to soften and relax forehead/scowl lines as well as crows feet around the eye area. Botox is an injectable substance that is a medical grade form of the botulinum toxin A. Botox has been used for years to treat muscle twitches, and has recently come into favor for creating a more youthful rested look when used on the upper third of the face. Botox is not always permanent and may have to be repeated for ongoing and optimal results.

Brand Name Drug: A prescription drug that has been patented and is only available through one manufacturer.

Breast Enlargement (Augmentation Mammaplasty): Breast implants are placed either above or below the pectoral (chest) muscle to enhance the bust area. There are many surgical options for this procedure, including, placement, shape, volume, type of fill and surface texture of the implant as well as where the incisions are made to place the implants. A thorough evaluation by the surgeon and knowledge of surgical options are key in the satisfaction of this procedure.

Breast Lift (Mastopexy): Aging, weight gain-loss or nursing can cause drooping or sagging breasts. Mastopexy is a way to re-suspend breasts that have lost their original shape and have become pendulous. A breast lift changes the shape of the breast, not the volume and lifts the nipple to the level of the crease underneath the breasts. Often, a breast augmentation (implants) can be offered in conjunction with a breast lift if there is a not adequate breast tissue

Breast Reconstruction: Reconstruction of the breast or breasts after breast cancer surgery is an option many women choose. There are several approaches for breast reconstruction including the use of implants or tissue donated from other parts of the body such as abdomen, thighs, hips and-or buttocks. The nipple and areola are also reconstructed usually in a separate operation or may be cosmetically tattooed to match the other or original breasts.

Breast Reduction (Mammaplasty): This procedure is performed to reduce the shape and volume of the breast. The nipple/areola usually are repositioned as large breasts tend to be more "ptotic" (drooping). For those considering this surgery there is a high satisfaction rate due to the emotional and sometimes physical discomfort that large breasts and early development can cause.

Breast Reduction in Men (Gynecomastia): Male breast reduction is often addressed with a combination of liposuction and surgical removal of breast tissue. Enlarged breasts on men can be caused by medications, excess body fat or linked to marijuana use.

Brow Lift: The brow lift or forehead lift addresses a drooping or "ptotic" forehead. There are two common techniques used for this procedure. A "coronal" brow lift incision is placed ear to ear across the top of the forehead. The excess tissue is removed and the brow is pulled up and sutured into the new lifted position. The "endoscopic" brow lift is performed with tiny incisions (approximately 4-6) that are placed at the hairline, and the brow is lifted and affixed to underlying tissue. This is often done in conjunction with eyelid surgery to produce a refreshed and youthful result on the top third of the face.

Back to top

 

Calendar year HSA contribution: The maximum amount you can contribute for the full calendar months that you are eligible to contribute. For example, if you are covered under an HDHP for only six months, then you will only be able to contribute half of the total maximum calendar year amount.

Case Management: A program that is designed to assess the continuing needs of members with catastrophic or chronic health problems. Case managers assist physicians in meeting an individual's health care needs through coordination of services and utilization of resources in order to promote high quality, cost effective outcomes.

Certification: The determination that an admission, availability of care, continued stay or other services, supplies or drugs has been reviewed and, based on the information provided, satisfies our requirements for medically necessary services and supplies, appropriateness, health care setting, level of care and effectiveness.

Cheek Augmentation (Malarplasty): Facial cheek implants are placed to improve the prominence of the cheekbones, to create facial feature harmony after a trauma or to enhance genetically smaller cheekbones. There are several options as to where the incision sites may be placed.

Chemical Peels: A chemical solution ranging from mild to strong is used on the face to soften or improve fine lines, wrinkles, skin tone or irregular pigmentation. Mild peels may be administered by an aesthetician (skin care specialist), whereas a doctor must perform stronger peels.

Chemotherapy: Treatment of malignant disease by chemical or biological antinoeplastic agents.

Chin Augmentation: This surgery is offered to correct a receding or "weak" chin in an effort to bring more balance to the profile. Implants are used to provide greater prominence. Chin augmentation is often accompanied by rhinoplasty surgery (nose reshaping).

Chiropractic Care: Chiropractic medicine is based on the relationship between the structure and function of the human body. Chiropractic care is rendered by a licensed chiropractor and is intended to support the spinal column and nervous system functions.

Claim: A request for payment for benefits received or services rendered.

COBRA (Consolidated Omnibus Budget Reconciliation Act): The federal law applying to groups of 20 or more that offers extended coverage for enrollees and family members after group coverage would normally end. A federal act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event. Qualifying events are those that result in a loss of coverage, such as reduced work hours, death or divorce of a covered employee, and termination of employment.

Coinsurance: Coinsurance is the percentage of the allowed amounts for covered services that BCBSNC will pay after you meet your deductible.

Important Information: Please be aware that some services and supplies received by members in an office setting or in connection with an office visit are in fact provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Prior to scheduling an appointment, please confirm with your provider whether the practice is hospital-owned or whether any services are hospital-based and may be subject to deductible and coinsurance.

Coinsurance Maximum: Coinsurance maximum is the total amount of coinsurance that a member is obligated to pay for covered services per benefit period.

Computer Imaging: Computer imaging is state-of-the-art technology allowing a patient to preview the potential outcome of a requested procedure. The patient's image is captured on the computer screen, and the technician "morphs" the features until a desired result is achieved. The computer representation should not be construed as an exact surgical result.

Conscious or IV Sedation: Conscious or IV (intravenous) sedation is the anesthetic approach, which causes the patient to be unaware but does not place him/her under full, general anesthesia.

Continuation: Allowing a covered person who would otherwise lose coverage under a health plan due to certain occurrences such as termination of employment or divorce to retain coverage under specified conditions (see COBRA).

Contraception: Contraceptive devices or medications used in the prevention of pregnancy.

Contract (Subscriber): A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. A subscriber could have two contracts (policies) - one for health and one for dental. Can also be called a Benefit Certificate or Policy.

Contract Holder: See subscriber.

Contributions: Money you (or someone else) deposits into your health savings account (HSA). Contributions are tax-deductible, and are subject to annual limitations outlined by the IRS and based on your health plan deductible.

Conversion Option: The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement.

Coordination of Benefits (COB): The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.

Copayment (or copay): The fixed-dollar amount which is due and payable by the member at the time a covered service is provided.

Important Information: Please be aware that some services and supplies received by members in an office setting or in connection with an office visit are in fact provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Prior to scheduling an appointment, please confirm with your provider whether the practice is hospital-owned or whether any services are hospital-based and may be subject to deductible and coinsurance.

Cosmetic Dermatologist: A cosmetic dermatologist is a doctor whose practice focuses on aesthetic or cosmetic procedures/treatments for the skin, such as laser resurfacing, chemical peels, etc. As of this date there is no specific board certification in cosmetic dermatology. Dermatologists are certified by the American Board of Dermatology.

Cosmetic Surgery : Cosmetic surgery focuses mainly on the enhancement or beautification of specific facial or body parts. It does not necessarily include reconstruction or restoration, except in specific cases, such as rhinoplasty-where both function (breathing, etc.) and form (removal of bump, etc.) are addressed.

Cost Sharing: A method of dividing the cost of healthcare among consumers, insurance companies, employers and providers. For example, your employer may pay part of the premiums for your insurance. Your health plan will pay part of your healthcare bills, and you will pay part. If your doctor is part of your health plan's network, then he or she will cover part of the cost by negotiating a discount for his or her services. Everyone shares in the cost to keep costs down.

Covered Service: Service, drug, supply or equipment specified which members are entitled to benefits in accordance with the terms and conditions of health plan.

CranioSacral Therapy: A manual therapy that involves a gentle, non-invasive palpation (touch by the practitioner) of the head, spinal column, and sacrum.

Credentialing: The process of licensing, accrediting, and certifying health care providers. Managed care companies often verify providers' credentials prior to allowing them to participate in a provider network.

Cupping: An Oriental medicine technique which utilizes a glass or bamboo cup to create a suction on the skin above a painful muscle or acupuncture point.

Custodial Care: Care comprised of services and supplies, including room and board and other facility services, which are provided to the patient, whether disabled or not, primarily to assist him or her in the activities of daily living. Custodial care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self-administration of medications. Such services and supplies are custodial as determined by BCBSNC without regard to the provider prescribing or providing the services.

Customary and Reasonable (C&R) : See Usual, Customary and Reasonable (UCR) Charge.

Back to top

 

Day Treatment Center (Mental Health): An outpatient psychiatric facility which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

Deductible: The amount of loss or expense for covered services that must be incurred by an insured before an insurer will assume any liability for all or part of the remaining cost of covered services.

Important Information: Please be aware that some services and supplies received by members in an office setting or in connection with an office visit are in fact provided by hospital-owned or operated practices. These services and supplies may be subject to your deductible and coinsurance. Prior to scheduling an appointment, please confirm with your provider whether the practice is hospital-owned or whether any services are hospital-based and may be subject to deductible and coinsurance.

Deductible amount: The amount your policy requires you to pay for services before it will assume any liability for all or part of the remaining cost of covered services.

Dental Care: Covered services which are necessary and appropriate for the treatment of teeth, gums and supporting structures.

Dermabrasion: Dermabrasion is a mechanical vs. chemical approach to reducing fine lines, wrinkles and acne scarring. A medical device is used to "sand" the skin. Dermabrasion is not used as often as chemical peels or laser resurfacing, yet some doctors have a preference for dermabrasion when dealing with uneven skin such as acne scarring or raised scars.

Dependent: Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate. Also called a "Member" or "Beneficiary".

Diagnostic Tests: Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Disease Management Programs (Health Management Programs): Educational programs designed for individuals with chronic diseases designed to help maintain high quality of life and prevent future need for medical resources by using an integrated, comprehensive approach to health care coordinate with the individual's physician. Pharmaceutical care, continuous quality improvement, practice guidelines, and case management all play key roles in this effort.

Distribution: Money you withdraw from your health savings accout (HSA). Withdrawals can be made in a variety of ways, including by using your HSA debit card or checkbook.

Doctor: A doctor of medicine, a doctor of osteopathy, licensed to practice medicine or surgery by the Board of Medical Examiners in the state of practice, a doctor of dentistry, a doctor of podiatry, a doctor of chiropractic, a doctor of optometry, or a doctor of psychology who must be licensed or certified in the state of practice and has a doctorate degree in psychology and at least two years clinical experience in a recognized health setting or has met the standards of the National Register of Health Services Providers in Psychology. All of the above must be duly licensed to practice by the state in which any service is performed.

Doctor Charges: Total doctor charges divided by total cases. If multiple doctors were involved in a case, total doctor charges includes all services billed by all doctors.

Drug Formulary: A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.

Durable Medical Equipment (DME): Items designated by BCBSNC which can withstand repeated use, are used primarily to serve a medical purpose, are not useful to a person in the absence of illness, injury or disease, and are appropriate for use in the patient's home.

Back to top

 

Ear Pinning (Otoplasty): Otoplasty is performed to correct or "pin-back" protruding ears. This is one of the few surgeries that can be performed on children before they enter school, in an effort to avoid teasing and ridicule. As one of the most satisfying procedures, there is a dramatic improvement in the appearance of the patient.

Effective Date: The date on which coverage for a member begins.

Electro-acupuncture: An Oriental medicine technique which uses mild, low-voltage electric stimulation of acupuncture points.

Eligibility: The provisions of the group policy or insurance contract that state requirements that applicants must satisfy to become insured with respect to themselves or their dependents.

Eligible Employee: An eligible employee is any employee who:

  • Works 30 or more hours per week on a year round basis
  • Has annual reporting of FICA withholdings by means of a W2
  • Is listed on the group's wage and tax statement

Emergency: The sudden or unexpected onset of a condition of such severity that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of an individual or with respect to a pregnant woman, the health of the pregnant woman or her unborn child in serious jeopardy, serious physical impairment to bodily functions, serious dysfunction of any bodily organ or part or death. Heart attacks, strokes, uncontrolled bleeding, poisonings, major burns, prolonged loss of consciousness, spinal injuries, shock, and other severe, acute conditions are examples of emergencies.

Emergency Care: Care for the sudden or unexpected onset of a condition of such severity that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of an individual or with respect to a pregnant woman, the health of the pregnant woman or her unborn child in serious jeopardy, serious physical impairment to bodily functions, serious dysfunction of any bodily organ or part or death. Heart attacks, strokes, uncontrolled bleeding, poisonings, major burns, prolonged loss of consciousness, spinal injuries, shock, and other severe, acute conditions are examples of emergencies.

Endoscopic Procedures: An endoscope is a medical video scope, which allows the surgeon to view inside the body through very small, limited incisions during surgery. An example of a cosmetic surgery procedure that can be performed endoscopically is a forehead or brow lift. This approach helps minimize scarring.

Enrollee: An individual who is enrolled and eligible for coverage under a health plan contract. Also called "Member".

Exclusions: Specific circumstances, conditions or services that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.

Experimental Procedures: See Investigational Procedures.

Expiration Date: The date indicated in an insurance contract as the date coverage expires.

Explanation of Benefits (EOB): A statement to the subscriber that explains the action taken on each claim.

Back to top

 

Facelift (Rhytidectomy): "Rhytids" are wrinkles - Rhytidectomy literally means the surgical removal of wrinkles. A facelift normally includes the mid-face/cheek area as well as the neck. This procedure will remove excess skin and usually addresses the underlying muscle and connective tissue or SMAS layer (superficial musculoaponeurotic system), then tighten the remaining skin to return the face to a more youthful presentation. A facelift only addresses sagging and loose skin. It does not change the texture or pigmentation of the facial skin.

Facial Plastic Surgeon: A facial plastic surgeon specializes in cosmetic and/or reconstructive surgery of the head and neck only. In most cases a facial plastic surgeon has been board certified in otolaryngology (ear, nose and throat - ENT) and proceeds to complete the board examination in facial plastic surgery. Facial plastic surgeons are certified by the American Board of Facial Plastic and Reconstructive Surgery, an ABMS equivalent board (has met or exceeded the standards put forth by ABMS).

Facility Name: The name of the facility. How information is collected: Application. When is the information updated: Time of recredentialing or when notified by the Facility.

Facility Services: Covered services provided and billed by a hospital or nonhospital facility. All services performed must be within the scope of license or certification to be eligible for reimbursement.

Fat Soluble Vitamins: Vitamins that dissolve in dietary and body fat (A, D, E, and K). They are metabolized and stored by the body in the same fashion as fats. Because excess fat-soluble vitamins may be stored in the body, several weeks' supply may be consumed in a single dose or meal.

Federal Tax Identifier: The federal identifier under which taxes are filed.

Fee-for-Service Reimbursement: A method of payment to providers on the basis of a charge for each procedure performed, including professional service, laboratory, x-ray, injections, etc.

Feldenkrais Method: A somatic education method taught in an individual or group setting that uses verbal and hands-on guidance to improve posture and flexibility. For more information, visit Feldenkrais Guild of North America. See also Hanna Somatics.

Formulary: See Drug Formulary.

Formulary tiers: BCBSNC uses a group of physicians and pharmacists throughout the state to recommend tier classifications. Each drug in the BCBSNC formulary is classified into one of four tier groups to determine the amount of coverage and copayment each requires. The Tier 4 Formulary applies to most but not all policies. Please refer to your benefit booklet to determine if the Tier 4 Formulary applies to you, or check your BCBSNC ID card for four levels of pharmacy copayment.

  • Tier 1: Generic drugs - All generic drugs. Lowest copayment
  • Tier 2: Preferred brand drugs - Brand name drugs that are clinically effective, cost-effective and meet the needs of most patients. Second-lowest copayment
  • Tier 3: Non-preferred brand drugs - Brand name drugs that do not have a generic equivalent, but have a therapeutic alternative available in Tier 2. Brand name drugs not usually used as the first line of treatment. Brand name drugs that have a generic equivalent. Second-highest copayment
  • Tier 4: Specialty drugs - Medications classified by BCBSNC as those that generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or therapies. Highest copayment or coinsurance amount.

Please note: If a member chooses a brand name drug when a generic equivalent is available, the member typically will be responsible for paying the difference between the cost of the generic drug and the brand name drug in addition to the higher tier copayment, unless the member's physician specifically states that the brand name drug is necessary.

Free Radicals: Also called oxidants, are unstable molecules that can attack the body's cells. Damaging a cell membrane can alter functions like bringing in nutrients, oxygen and water, or expelling wastes. Eventually, free radical damage can kill the cell. Free radicals can be produced by trauma, injury, sunlight, pollution, exposure to toxins, alcohol and cigarette consumption, and some foods. They are also a byproduct of many of the body's natural processes.

Full months covered: The number of full months you have been covered under your policy during the calendar year. For example, for a policy that became effective on June 15, the months covered for the calendar year would actually begin on July 1 and end December 31.

Back to top

 

Gatekeeper: A primary care physician who serves as the patient's initial contact for medical care, and who makes referrals. The gatekeeper's function is to optimize health care utilization, and costs, without sacrificing quality of care delivered.

Generic Drug: A non-brand name drug which has the same active ingredient, strength and dosage form, and which is determined by the FDA to be therapeutically equivalent to the drug product identified in the prescription.

Generic Drug Initial Copayment Waiver: The initial copayment for a new generic prescription of this drug will be automatically waived.

Group: An employer or other entity that has entered into a contract for health care and/or administration of benefits for its eligible members.

Guided Imagery: Interactive Guided Imagery SM is a process using the power of the mind to evoke a positive physical response. Guided Imagery can reduce stress and slow the heart rate, stimulate the immune system and reduce pain. For more information, visit The Guided Imagery Resource Center.

Back to top

 

Hair Restoration: Hair restoration procedures are designed to restore or improve the natural hairline. There are many options available for hair restoration - from medications to hair follicle transplantation. Hair restoration may require a minimum of several sessions.

Hanna Somatics: A somatic education method derived from Feldenkrais that uses slow-motion movement techniques to release unconscious and habitual muscle tensions.

Health Benefit Plan: A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services and a provider network.

Health Care Financing Administration (HCFA): A division of the federal Department of Health and Human Services which administers the Medicare and Medicaid programs.

Health Insurance Portability and Accountability Act (HIPAA): A federal health benefits law passed in 1996, effective July 1, 1997, which among other things, restricts pre-existing condition exclusion periods to ensure portability of health-care coverage between plans, group and individual; requires guaranteed issue and renewal of insurance coverage; prohibits plans from charging individuals higher premiums, co-payments, and/or deductibles based on health status.

Health Maintenance Organization (HMO): A type of health care plan under which the enrollees receive all the medical services they need through a specific group of participating doctors and hospitals.

Hearing Services: Services related to hearing and the hearing structures of the ear.

Herbal Medicine: An Oriental medicine practice for the prescription of therapeutic foods or herbs.

High: 75 percent of the reported cases have a value less than or equal to this value.

High deductible health plan (HDHP): A federally defined health benefit design that qualifies someone to open an health savings account (HSA). Members covered under high deductible health plans do not have benefits for any coverage (e.g., office visits, emergency room visits and prescription drugs) prior to meeting the deductible (with the exception of preventive care).

HMO: See Health Maintenance Organization.

Home Health Care: Health services rendered in the home to an individual who is confined to the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care, but who do need nursing services or therapy, medical supplies and special outpatient services.

Home Infusion Therapy: The administration of intravenous drug therapy in the home. Home Infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.

Hospice: A non-hospital facility that provides medically related services to persons who are terminally ill.

Hospital: An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

Hospital Cost: Total hospital charges divided by total cases.

Hospital Days: Total number of days a patient stays in a hospital after admission to the hospital. Also known as length of stay. (LOS)

HSA catch-up contribution: The contribution amount allowed for individuals (and their spouses covered under the HDHP) who turn 55 during the calendar year and are also not enrolled in Medicare. The HSA contribution limit is increased by specified amounts in each calendar year.

HSA eligible: The contribution amount allowed for individuals (and their spouses covered under the HDHP) who turn 55 during the calendar year and are also not enrolled in Medicare. The HSA contribution limit is increased by specified amounts in each calendar year.

Hyperopia: (Farsightedness) Hyperopia causes blurred vision when objects are viewed at close range or at a distance. It occurs when light rays entering the eye improperly focus behind the retina. Hyperopia can occur when the eye is too short or the cornea is too flat.

Back to top

 

I.D. Card/Identification Card: The card issued to members upon approval of the request for Enrollment Application and Change Form.

Indemnity: Traditional fee-for-service health insurance in which a subscriber has free choice of physicians. The coverage usually includes a deductible and co-insurance. The Plan pays for a certain percentage of charges billed by the provider, and the member is responsible for the rest.

Immunizations: Vaccines against specific diseases that can be administered either orally or by injection.

Implant Materials: Implant materials consist a variety of synthetic and non-synthetic (organic) material that is used to augment or enhance a facial or body part, such as breast implants, chin implants or other soft tissue fillers (collagen, Gore-tex, etc.).

In-Network: Refers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee's out-of-pocket expense.

In-Network Provider: A provider that has been designated as a participating or contracted provider by BCBSNC for the member's specific health insurance product.

Individual Insurance: Health care coverage for individuals or single family units.

Infertility: The inability of a heterosexual couple to conceive a child after 12 months of unprotected male/female intercourse.

Informed Consent: Informed consent correlates to signing forms that legally allow the surgery to proceed. Informed consent assumes that the patient has read about, been educated and understands all of the events, risks and complications that could take place as a result of surgery.

Infusion Therapy: Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding.

Inpatient: Services received when a member is admitted to a hospital or non-hospital facility as a registered bed patient for whom a room and board charge is made.

Investigational Procedures: Procedures that are not recognized by the Plan as standard medical care for the condition, disease, illness or injury being treated, including, but not limited to, diagnostic service, treatment, facility, equipment, drug or device. A service is considered investigational (experimental) if any of the following criteria are met:

  1. The services, procedures or supplies requiring Federal or Governmental body approval, such as drugs and devices, do not have unrestricted market approval from the Food and Drug Administration (FDA) or final approvals from any other governmental regulatory body for use in treatment of a specified condition. Any approval that is granted as an interim step in the regulatory process is not a substitute for final or unrestricted market approval.
  2. There is sufficient or inconclusive medical and scientific evidence to permit the Plan to evaluate the therapeutic value of the service, procedure or supply. (Adequate evidence is defined as at least two documents of medical and scientific evidence that indicate that the proposed treatment is likely to be beneficial to the member.)
  3. There is inconclusive medical and scientific evidence in peer-reviewed medical literature that the service, procedure or supply has a beneficial effect on health outcomes.
  4. The service, procedure or supply under consideration is not as beneficial as any established alternatives.
  5. There is insufficient information or inconclusive scientific evidence that, when used in a non-investigational setting, the service, procedure or supply has a beneficial effect on health outcomes or is as beneficial as any established alternatives.

Back to top

 

LASIK (Laser Assisted In Situ Keratomileusis): The most common laser vision correction technique. During the LASIK procedure, a thin flap of the cornea is lifted, then the cornea is reshaped using laser pulses. After the cornea is reshaped, the corneal flap is replaced, unlike with PRK, and recovery time is shorter.

Laser Resurfacing: A laser beam is used to remove the top layer of skin, addressing wrinkles and fine lines, giving way to fresh, new skin underneath. The term laser is an acronym for Light Amplification by Stimulated Emission of Radiation. A lot of attention has been given to lasers, as if the use of laser technology is safer or less invasive. Laser resurfacing (the first generation) does break the skin barrier, is still invasive surgery and must be entered into with caution.

Length of Stay (LOS): The number of days that a member stayed in an inpatient facility.

Level One Services: Primary Care / Preventive Care

Primary Care: With Blue Options 1-2-3, you will receive the highest level of benefits by receiving preventive care services and other office-based services from a Primary Care Physician (PCP). PCPs are trained to deal with a broad range of health care issues and can help you to determine when you need a specialist.

Preventive Care: Medical services provided by or upon the direction of a doctor or other provider related to the prevention of disease

Services normally considered Preventive Care:

  • Routine wellness exams
  • Immunizations and vaccination
  • Diagnostic Procedures (Pap Test, Mammography, Colorectal Screening, etc)
  • Well Baby Care
  • Well Woman Care
  • Prostate Exam

Level Two Services: Inpatient and related services

Examples include but are not limited to:

  • Inpatient Hospital Services
  • Home Health Care
  • Hospice Care
  • Skill Nursing Facility Care
  • Inpatient MH / SA
  • Ambulance
  • ER (admitted)

Level Three Services: Outpatient and Specialist Services

Examples include but are not limited to

1. Outpatient Hospital Services

  • Lab and Radiology
  • Outpatient Surgery
  • Physical, Speech, and Occupational Therapy
2. ER (not admitted)

3. Ambulatory Surgery Center

4. Specialist Office Visits

  • Office Based Surgery
  • Non-Preventive Office Based Services (includes Lab and Radiology)
  • Therapy Services: PT, OT, ST
5. Outpatient Mental Health

Lifetime Maximum: The maximum amount of covered services that will be provided to a member while they have coverage under this health benefit plan.

Lip Augmentation: Lip augmentation is a procedure to enhance the fullness of lips. This is accomplished either by injection of a soft tissue filler, such as collagen or by the placement of synthetic or grafted material.

Liposuction (Lipoplasty): Liposuction is the vacuum assisted removal of fat and the number-one cosmetic surgery procedure for both men and women. A "cannula" (long-thin vacuum probe) is used to extract the fat. There are several techniques offered by surgeons for this procedure. The most common - the "tumescent" technique introduces an anesthetic solution to help reduce blood loss and bruising. Small incisions are made at specific sites on the body, depending upon the areas to be addressed.

Location: The service location of the facility. How information is collected: Application. When is the information updated: Time of recredentialing or when notified by the Facility.

Low: 25 percent of the reported cases have a value less than or equal to this value.

Back to top

 

Mailing Address: The address used for receipt of postal delivery.

Managed Care: A health care delivery system, comprising a spectrum of financial and structural relationships among purchasers, insurers, providers and members, designed to favorably affect the balance of access, cost, and quality of health care for a defined population of subscribers and members.

Manual Lymph Drainage: A massage technique which uses gentle, rhythmic pressure to stimulate lymphatic flow.

Manual Therapies: Any hands-on technique, especially therapeutic manipulation of body structure, e.g., deep tissue or connective tissue. See also CranioSacral Therapy, MyofascialRelease, PolarityTherapy, Reflexology, Reiki, Rolfing, RosenMethod, TherapeuticTouch and TriggerPoint/Myotherapy.

Massage: Any hands-on technique for relaxation or health enhancement. For more information, visit American Massage Therapy Association.  See also Shiatsu Massage, Sports Massage, Swedish Massage, and Therapeutic Massage

Maternity Care: The care and treatment related to pregnancy and delivery of a newborn child.

Medicaid: A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

Medicaid Provider Number: The number under which you file Medicaid claims.

Medical Equipment: See Durable Medical Equipment (DME).

Medical savings account: A tax-exempt trust or custodial account established for the purpose of paying medical expenses in conjunction with a high-deductible health care plan. The MSA is the former name for what is now called the health savings account in the United States. The provisions of the MSA were made more advantageous and available to more people in the new HSA. The changes were made in legislation signed by George W. Bush on December 8, 2003.

Medical Group Affiliation(s), If Applicable: A medical group with which the doctor contracts. How information is collected: Initial Application. When is the information updated: At such time notified by BCBSNC Network Management or when group sends notice and subsequently confirmd via verification of data in Power or NM. Limitations: Rely on notification of NM or the Group.

Medical Supplies: Disposable health care materials that include ostomy supplies, catheters, oxygen and diabetic supplies.

Medically Necessary: Those covered services or supplies that are:

  1. provided for the diagnosis, treatment, cure or relief of a health condition, illness, injury or disease;
  2. not for experimental, investigational or cosmetic purposes;
  3. necessary for and appropriate to the diagnosis, treatment, cure or relief of a health condition, illness, injury, disease or its symptoms;
  4. within generally accepted standards of medical care in the community;
  5. not solely for the convenience of the insured, the insured's family or the provider.

Medicare: The program of health care for the aged, disabled and individuals with end stage renal disease established by Title XVIII of the Social Security Act of 1965, as amended.

  • (Part A) - Covers Medicare beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services for a limited duration. Beneficiaries are responsible for deductibles and copayments. Part A services are financed by the Medicare Hospital Insurance Trust Fund.
  • (Part B) - Covers Medicare beneficiaries for physician services, medical supplies and other outpatient treatment. Beneficiaries are responsible for monthly premiums, copayments, deductibles, and balance billing. Part B services are financed by a combination of enrollee premiums and general tax revenues.

Medicare Supplemental: A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.

Member: A subscriber or dependent, whose Enrollment Application or Change Form has been accepted and for whom premium is paid.

Member ID card: The card issued to a subscriber by BCBSNC as evidence of membership. This card lists the subscriber ID number, all policy members, copay/coinsurance information, customer service phone numbers and more.

Mental Health/Behavioral Health: Mental disorders, psychiatric illnesses, mental illnesses, mental conditions and psychiatric conditions (whether organic or non-organic, whether of biological, nonbiological, chemical or nonchemical origin and irrespective of cause, basis or inducement). This includes, but is not limited to, psychoses, neurotic disorders, schizophrenic disorders, affective disorders, personality disorders, and psychological or behavior abnormalities associated with transient of permanent dysfunction of the brain or related neurohormonal systems.

Monthly HSA contribution: The monthly HSA contribution amount, if you choose to contribute monthly.

Moxibustion: An Oriental medicine technique for the application of heat to an acupuncture point by burning an herb called moxa (artemisia vulgaris) near the skin or on top of a slice of ginger.

Myopia - (Commonly called nearsightedness.): Myopia causes objects viewed at a distance to appear distorted or blurry. It occurs when light rays entering the eye fall short of the retina. Myopia can occur from a cornea that is too curved or an eyeball that is too long.

Myotherapy: See Trigger Point/Myotherapy.

Myofascial Release: A manual therapy technique which works on underlying connective tissue or trigger points to facilitate the release of chronic muscular tensions restricting posture, movement and circulation.

Back to top

 

National Committee for Quality Assurance (NCQA): Not-for-profit accrediting organization that performs quality-oriented reviews of HMOs and similar types of managed care plans.

NPI-National Provider Identifier: The National Provider Identifier (NPI) for your provider group or entity. The NPI is the national standard unique health identifier for health care providers. This number is required as of May 23, 2007.

NC Medicaid Provider: If you provide Medicaid services for the state of North Carolina, select the YES radio button.

Negotiated Rate: The amount participating providers agree to accept as payment in full for covered services. It is usually lower than their normal charge. Negotiated rates are determined by Participating Provider Agreements.

Network: A group of physicians, hospitals and other health care providers working with a health care plan to offer care at negotiated rates and at other agreed upon terms.

Network Provider:  See also Participating provider

Non-Hospital Facility: An institution or entity other than a hospital which is accredited and licensed or certified in the state where located.

Non-Participating Provider: A medical provider who has not contracted with a health plan as a participating provider.

Non-preferred Brand Drugs: Brand name drugs that do not have a generic equivalent, but have a therapeutic alternative Preferred brand drug available.

  • Brand name drugs not usually used as the first line of treatment.
  • Brand name drugs that have a generic equivalent.
  • Second-highest copayment.

No appointments available: This provider's schedule is full; this provider is not accepting any additional patients. How information is collected: Information is indicated by the provider at upon initial contracting or renewal of contract. When is the information updated: When the provider updates BCBSNC to a change in status.

Nutrition Counseling: Qualified practitioners provide nutritional counseling and education through one-on-one sessions, as well as group classes. A variety of topics are covered, including weight management, nutrition for health and wellness and vegetarian eating. Practitioners in this field include both licensed dietitians and nutrition counselors. For more information, visit American Dietetic Association or Nutrition Navigator.

Back to top

 

Occupational Therapy: See Short-Term Rehabilitative Therapy

Office Visit: Represents the type and level of office visit. Factors that determine the office visit category include complexity of the visit and the time spent with the provider.

Open Enrollment: a) A period during which subscribers in a health benefit program have an opportunity to make changes in their health coverage (select an alternative program, for instance); or b) a period when uninsured individuals can obtain coverage without presenting evidence of insurability (health statements).

OTC: An OTC (over-the-counter) medication is any medication that can be purchased without a prescription. There are OTC medications on the market that effectively treat many common health conditions, including allergies, heartburn, and arthritis.

Over the Counter (OTC): Any medication that can be purchased without a prescription.

Out of Network: Services performed by a provider who has not signed a contract with the member's health plan to be part of a provider network.

Out of Network: With the Blue Options 1-2-3 plan, you may choose to receive covered services from a provider that is not designated as participating in the Blue Options 1-2-3 network, and benefits will be paid at the lower out-of-network level.

Out-of-Network Provider: A provider that has not been designated as a participating or contracted provider by BCBSNC for the member's specific health insurance product.

Out-of-Pocket Costs: Coinsurance payments made by an individual for covered medical services. In addition, this may include deductible amounts for some products, such as Blue Options HSA.

Out-of-Pocket Maximum: Refers to the maximum coinsurance amount that a member is required to pay for covered services during a benefit period. Deductibles, copayments, noncovered services and amounts exceeding the allowed amounts for covered services do not apply to the "out-of-pocket" maximum.

Outpatient: Services received from a hospital or non-hospital facility while not an inpatient.

Outpatient Surgery: Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.

Back to top

 

Partial Day Treatment: A program offered by appropriately licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

Participating Provider: A hospital, doctor, pharmacy, or other provider designated by a health plan to provide care or services to members. Benefits are available only for covered services and must be within the scope of the provider's license. For certain benefits, a participating provider may include a facility, agency, or organization that has an agreement with the plan to provide services to covered members  See also Network provider

PCP: See Primary Care Physician

Per Admission Copay: The fixed-dollar amount that is due and payable by the member for an admission to the hospital inpatient setting.

Physical Therapy: Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.

Place of Service: Location that a service is rendered to a member. Examples include inpatient hospital doctor's office, ambulatory surgery center, and outpatient hospital.

Plan Benefit Maximum: See Lifetime Maximum

Plastic Surgeon: A plastic surgeon specializes in cosmetic and/or reconstructive surgery of the face and body. Plastic surgeons are certified by the American Board of Plastic Surgery - an ABMS (American Board of Medical Specialties) member board.

Plastic Surgery: Plastic surgery is a field of medical practice that concentrates on both the enhancement and refinement of specific features of the body, as well as restoring or reconstructing facial or body parts.

Point of Service (POS): A product line that combines the cost and care management strengths and comprehensive benefits of an HMO with the freedom of choice of a preferred provider organization. The member determines the benefit level by choosing the point of service - in or out of network.

Polarity Therapy: A manual therapy that combines the holding of pressure points and gentle stretching to balance the body's energy.

Policy Type: Name of the BCBSNC health plan and the associated covered services.

Preferred Provider Organization (PPO): A health plan that contracts with various physicians and hospitals. Enrollees are offered a financial incentive to use providers on a preferred list, but many use non-network providers as well.

Pre Authorization: A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.

Pre-Certification: Utilization management program that requires the individual or provider to notify the insurer before hospitalization or surgical procedures.

Pre-Existing Condition: A condition, disease, illness or injury for which medical advice, diagnosis, care or treatment was received or recommended within a specified time period prior to enrolling in health plan. Pregnancy and genetic information are not considered pre-existing conditions.

Preferred Brand Drugs: Brand name drugs that are clinically effective, cost effective and meet the needs of most patients.

  • This is the second-lowest copayment

Premium: The amount paid to keep an insurance policy active.

Prescription: A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.

Preventive Care: Medical services related to the prevention of disease, provided by or upon the direction of a doctor or other provider.

Preventive Care Copay: The fixed-dollar amount that is due and payable by the member at the time a Level 1 covered preventive care service is provided by primary care or specialist physician in the office setting.

PRK (Photorefractive Keratectomy): A corrective laser vision technique that uses a series of laser pulses to reshape the surface of the cornea.

Primary Care Copay: The fixed-dollar amount that is due and payable by the member at the time a Level 1 covered primary care service is provided in the office setting.

Primary Care Physician (PCP): A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient's regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.

Prior Authorization: The process of obtaining advanced approval of coverage for a health care service or medication. Also called Pre-Authorization.  See also Prior approval

Prorated maximum calendar year HSA contribution: The maximum amount you can contribute based on the month when your insurance policy became effective.

Prosthetic Devices: Fixed or removable artificial limbs or other body parts, which replace absent natural ones.  See also Prosthetic Appliances

Provider: A hospital, non-hospital facility, doctor or other provider, accredited, licensed or certified where required in the state of practice, performing within the scope of license or certification. All services performed must be within the scope of license or certification to be eligible for reimbursement.

Provider Name: The group or entity provider name under which claims are filed to BCBSNC.

Provider Network: A set of providers contracted with a health plan to provide services to the enrollees. In the case of a "fee-for-service" or non-network health plan, the provider network is generally all licensed providers of covered services.

Back to top

 

Qi Gong: An ancient "soft" Chinese martial art form combining movement, mindful meditation, and focused breathing as a means of cultivating qi, or chi, throughout the body for perceived health benefits and spiritual insights. The slow gentle movements are thought to promote self-healing, strengthen the immune system, release tension and stimulate vitality. Tai Chi, which has more complex movements, originated from the practice of QiGong.  See also Tai Chi

Quantity Limitations: Designed to identify the excessive use of drugs that may be dangerous in large quantities and to highlight the potential need for a different type of treatment. The Quantity Limitations program sets quantity limits on a small number of medications. BCBSNC will cover the drug up to the designated quantity. If the prescribing doctor feels it is medically necessary to exceed the set limit, they must get prior approval from BCBSNC before the higher quantity can be covered.

Back to top

 

Radiation Therapy: Treatment of disease by x-ray, radium, cobalt or high energy particle sources.

Reasonable and Customary: See Usual, Customary and Reasonable (UCR) Charge.

Referral: A recommendation by a physician for a member to receive care from a participating specialist or facility.

Reflexology: A manual therapy which uses pressure applied to reflex zones on the feet which correspond to other body areas. See also Therapeutic Massage.

Reiki: A manual therapy in which the practitioner's palms are held over the body to direct the flow of life energy in the manner of a laying-on of hands technique.

Respiratory Therapy: Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

Retrospective Review: A manner of judging medical necessity and appropriate billing practices for services that have already been rendered.

Rhinoplasty (Nose Reshaping): Commonly known as a "nose job," a rhinoplasty repositions or refines nasal features. There are two parts to a Rhinoplasty; 1) Septoplasty which addresses functions of the nose, such as breathing and 2) the Rhinoplasty which addresses form or aesthetics, such as the removal of a hump or the refinement of the tip of the nose.

Rolfing (Structural Integration): A manual therapy which manipulates deep tissue to bring the major segments of the body-head, shoulder, thorax, pelvis and legs-into a better vertical alignment with gravity. For more information, visit The Rolf Institute.

Rosen Method: A manual therapy which uses gentle touch and verbal exchange between practitioner and client to help draw the client's attention to areas of tension.

Back to top

 

Second Opinion: Usually used to refer to second surgical opinions. A patient may obtain opinions from more than one provider as the best course of treatment. Some health plans require second opinions while other encourage them or make them voluntary.

Service Area: The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

Shiatsu: A massage technique which applies pressure to points and meridians on the surface of the body.

Short-Term Rehabilitative Therapy: Services and supplies both inpatient and outpatient, ordered by a doctor or other provider to promote the recovery of the member from an illness, disease or injury when provided by a doctor, other provider or professional employed by a provider licensed by the appropriate state authority in the state of practice and subject to any licensure or regulatory limitation as to location,manner of scope of practice.

  1. Occupational Therapy - treatment by means of constructive activities designed and adapted to promote the restoration of the person's ability to satisfactorily accomplish the ordinary tasks of daily living and those required by the person's particular occupational role after such ability has been impaired by disease, injury of loss of a body part.
  2. Physical Therapy - treatment by physical means, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles and devices to relieve pain, restore maximum function and prevent disability following disease, injury or loss of body part.
  3. Speech Therapy - treatment for the restoration of speech impaired by disease, surgery, or injury; or certain significant physical congenital conditions such as cleft lip and palate.
  4. Skilled Nursing Facility (SNF): A non-hospital facility licensed under state law that provides skilled nursing, rehabilitative and related care where professional medical services are administered by a registered or licensed practical nurse. All services performed must be within the scope of license or certification to be eligible for reimbursement.

Skilled Nursing Facility (SNF): A non-hospital facility licensed under state law that provides skilled nursing, rehabilitative and related care where professional medical services are administered by a registered or licensed practical nurse. All services performed must be within the scope of license or certification to be eligible for reimbursement.

Soft Tissue Fillers: Soft tissue fillers are substances that are injected or implanted into a body part to make it plumper, more even and aesthetically pleasing. Collagen and fat are commonly injected into lips and facial creases, although the permanency is limited. Synthetic materials are often shaped and then implanted into lips and facial folds for a more lasting approach. The number of fillers available continues to increase rapidly. A thorough evaluation of your options is recommended, as not all fillers work well for everyone.

Somatic Education: Any body education method for improved balance, posture, integration and/or ease of movement. The two most common methods are the Alexander Technique and the Feldenkrais Method. See also Hanna Somatics.

Speech Therapy: Treatment of the correction of a speech impairment which resulted from birth, or from disease, injury, or prior medical treatment.

Specialists: Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), or specific procedures (e.g., oral surgery).

Specialty: The specific area of medicine a doctor practices in. How information is collected: Originally collected off of the credentialing application. updated upon requests at time credentialing for such specialty is approved. When is the information updated: Updated upon requests at time credentialing for such specialty is approved.

Specialty Drug: Medications classified by BCBSNC as those that generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or therapies.

Sports Massage: Any techniques used to assist an athlete to train or perform, but especially Swedish massage or joint movement, relaxation and mobilization techniques.  See also Massage

Subscriber: The person whose name appears on the identification card issued by the Plan and who is enrolled according to the records of the Plan. In the context of a group insurance plan, the subscriber is the individual who belongs to the group (e.g., employee); members consist of subscribers together with their covered dependents.

Substance Abuse/Chemical Dependency: Use of drugs in a manner or quantity other than directed; chemical dependency is the compulsion to take drugs to produce a desired effect.

Surgical Facility Accreditation (in a doctors office setting): Facility accreditation involves a rigorous and lengthy process that surgical suites or operating rooms undergo in order to ensure the highest level of quality and safety. Since this process is voluntary, when a doctor chooses to go through the accreditation process it is an indicator of high standards for delivering quality care.

Swedish Massage: This most common form of massage uses strokes, manipulations and movements to stimulate, relax or rehabilitate the body.

Back to top

 

Tai Chi ("Tai chi chuan"): An ancient "soft" Chinese martial art form and a means of cultivating the qi, or chi, for perceived health benefits and spiritual insights. Tai Chi originally stemmed from the ancient practice of qi gong, and consists of many qi gong movements, but has evolved to a distinct and separate martial art form. The slow gentle movements are thought to promote strength, balance, health, vitality, and an over-all sense of well-being.  See also Qigong

Termination date: Last date for which a member's enrollment is in effect for the most recent continuous coverage period under any plan.

Therapeutic Massage: Any massage for health enhancement (for example, acupressure, Swedish, neuromuscular or reflexology) as opposed to massage strictly for pleasure or relaxation.

Therapeutic Touch: A manual therapy akin to laying-on of hands in which the practitioner's palms are held near the body to affect the energetic fields.

Tier: A tier is the level of member copayment for a specific prescription drug under a drug benefit plan. Tier 1 medications are generic medications and have the lowest copayment. Tier 2 medications are preferred brands and have the second-lowest copayment. Tier 3 medications are non-preferred brands and have the second-highest copayment. Tier 4 medications are specialty drugs and have the highest copayment. Please refer to your benefit booklet to determine if the Tier 4 Formulary applies to you, or check your BCBSNC member ID card for four levels of pharmacy copayment.

Total Cost: Also referred to as billed charges. Total hospital and/ or doctor charges billed by the provider. Charges represent the gross billed or retail price of services. Charges do not necessarily represent the amount paid by the member or the amount collected by the provider.

Total Out-of-pocket Maximum: Also referred to as billed charges. Total hospital and/ or doctor charges billed by the provider. Charges represent the gross billed or retail price of services. Charges do not necessarily represent the amount paid by the member or the amount collected by the provider.

Trigger Point/Myotherapy: A manual therapy technique which releases knots of muscle tension which refer pain to other areas followed by gentle stretches or movement to retrain the muscles.

Back to top

 

Usual, Customary and Reasonable (See MG): A "usual" charge is the amount that is most consistently charged by an individual physician for a given service. A "customary" charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A "reasonable" charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under a UCR Program, the payment is the lowest of the actual billed charge, the physician's usual charge or the area customary charge for any given covered service.

Urgent Care: Services provided for a condition that occurs suddenly and unexpectedly, requiring prompt diagnosis or treatment, such that in the absence of immediate care the individual could reasonably be expected to suffer chronic illness, prolonged impairment or require a more hazardous treatment. Examples of urgent care include sprains, some lacerations and dizziness.

User Name: The name of the person(s) who will have a Blue e account (a user name, login ID, and password).

Utilization Management: A process of integrating review and case management of services in a cooperative effort with other parties, including members, groups, providers and payers to optimize the appropriate placement of patients to receive appropriate services/supplies.

Utilization Review: Evaluation of the necessity, appropriateness, and efficiency of the use of medical services, procedures and facilities.

Back to top

 

Vein Therapy (Sclerotherapy): Sclerotherapy is the procedure to address the removal of varicose and spider veins. The two most common types of vein therapy are saline/chemical solutions injected into the vein and laser therapy. Laser therapy is usually effective on smaller areas of spidering.

Back to top

 

Water Soluble Vitamins: Vitamins that dissolve in water (C and B-complex). They are easily absorbed and released by body tissues. The body cannot store water-soluble vitamins, so a daily supply is needed. Vitamin B-12 is the exception. If enough B-12 has been consumed, the body can store adequate amounts for several months.

Wellness Program: A health management program that incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability, which respond positively to lifestyle related interventions. Programs are designed to integrate with existing health care benefits; e.g., flex benefits, HMO, PPO; support the reduction in the demand for health care resources; and address the issues of dependent coverage and services for high-risk employees.

Back to top

 

Yoga: An ancient practice that strengthens and tones muscle, improves balance and flexibility, while increasing blood flow and vitality. While there are six distinct forms of yoga, most involve physical movements and holding of postures, while incorporating breathing and mindful attention. Many of the yoga studios incorporate a blend of yoga styles and offer a variety in levels of rigor.

Back to top