The meanings of key insurance terms are shown below.
| Accidental injury |
Physical harm or disability which is the result of
a specific unexpected incident caused by an outside force. Accidental
injury does not include illness or infection, except infection of
a cut or wound. |
| Ambulatory Surgical Center |
Ambulatory surgical centers are outpatient surgical facilities
that may be freestanding or located on the same grounds as a hospital.
They are licensed separately as outpatient clinics according to
state and local laws and meet all requirements of an outpatient
surgical clinic, as well as accreditation standards of the Joint
Commission on Accreditation of Health Care Organizations or the
Accreditation Association of Ambulatory Health Care.
|
| Ancillary Services |
Services rendered by health care providers other than
a physician (as defined below), such as laboratory, radiology or
other diagnostic imaging, physical therapy or other services. |
| Annual maximum |
The amount of payments for medical services that an insurance
plan will make in a year. Any amounts incurred during the year above
the annual maximum are the insured person's responsibility. |
| Co-insurance |
A percentage of the cost of services that the insured person
has to pay. For example, a plan may pay 80% of the charges and you
pay 20%. |
| Co-pay |
The amount that an insured person must pay for a covered service,
in addition to the insurance payment. For example, most HMOs have
a co-payment of $10 for each doctor's office visit and $250 for
each hospitalization. |
| Covered expense |
Medical expenses incurred by an insured person that
meet Anthem Blue Cross requirements for being eligible for benefit
payments. |
| Customary and Reasonable (C&R) |
A Customary and Reasonable charge, as determined annually
by Anthem Blue Cross, is a charge which falls within the common
range of fees billed by a majority of physicians for a procedure
in a given geographic region, or which is justified based on the
complexity or the severity of treatment for a specific case. When
a non-Prudent Buyer physician is used, the patient is responsible
for payment of all charges in excess of the Anthem Blue Cross C&R
payment. |
| Deductible |
The amount that must be paid by the insured person for health
care services before Anthem Blue Cross will pay claims.
|
| Emergency |
An emergency is a sudden, serious, and unexpected
acute illness, injury or condition (including sudden and unexpected
severe pain) that you reasonably perceive could permanently endanger
your health if medical treatment is not received immediately. Anthem
Blue Cross has sole and final determination as to whether services
were rendered in connection with an emergency. |
| Emergency Services |
Services provided in connection with the initial treatment
of a medical or psychiatric emergency. |
| Hospice |
An agency or organization primarily engaged in providing palliative
care (pain control and symptom relief) to terminally ill persons
and supportive care to those persons and their families to help
them cope with the terminal illness. This care may be provided
in the home or on an inpatient basis. A Hospice must be certified
by Medicare as a hospice, recognized by Medicare as a hospice
demonstration site, or accredited as a hospice by the Joint Commission
on Accreditation of Health Care Organizations.
|
| Hospital |
A Hospital is a facility that provides diagnosis,
treatment and care for persons who need acute inpatient hospital
care under the supervision of physicians. It must be licensed as
a general acute care hospital according to state and local laws.
It must also be registered as a general hospital by the American
Hospital Association and meet accreditation standards of the Joint
Commission on Accreditation of Health Care Organizations. For the
limited purpose of inpatient care, the definition of hospital also
includes psychiatric health facilities (only for the acute phase
of a mental or nervous disorder), and residential treatment centers. |
| Lifetime maximum |
The amount of total claims payments an insurance plan will make
for one patient the entire time they are covered by the plan. Any
amounts above the lifetime maximum are your responsibility. |
Limited Fee Schedule/
Non-Negotiated Rate/
Non-Network Rate |
The amount paid to providers who are not members of
the Anthem Blue Cross Prudent Buyer Plan, usually a percentage of
their total billed charges. Only a portion of the amount that a
non-participating provider charges for services is a covered expense
under SHIP; the patient is responsible for all charges above the
coverage level. |
| Medically Necessary |
Medically Necessary services or supplies are those Anthem Blue
Cross determines to be:
- Appropriate and necessary for the diagnosis or treatment of
the medical condition;
- Provided for the diagnosis or direct care and treatment of
the medical condition;
- Within standards of good medical practice of the organized
medical community;
- Not primarily for your convenience, or for the convenience
of your physician or another provider; and
- The most appropriate procedure, equipment, supply or level
of service that can safely be provided. The most appropriate
service or supply must satisfy the following requirements:
- There must be valid scientific evidence demonstrating
that the expected health benefits from the procedure, equipment,
service or supply are clinically significant and produce
a greater likelihood of benefit without disproportionately
greater risk of harm or complications for you with the particular
medical condition being treated than other possible alternatives;
and
- Generally accepted forms of treatment that are less invasive
have been tried and found to be ineffective or are otherwise
unsuitable.
- For hospital stays, acute care as an inpatient is necessary
due to the kind of services you are receiving or the severity
of your condition, and safe and adequate care cannot be
received by you as an outpatient or in a less intensified
medical setting.
In determining medical necessity, Anthem Blue Cross will take
into account the results of a review by its medical director and/or
by independent medical professionals selected by Anthem Blue Cross,
including professionals who treat the type of disease or condition
involved.
|
| Mental or nervous disorders |
Mental or nervous disorders, for the purposes of this plan, are
conditions that affect thinking and the ability to figure things
out, perception, mood and behavior. A mental or nervous disorder
is recognized primarily by symptoms or signs that appear as distortions
of normal thinking, distortions of the way things are perceived
(e.g., seeing or hearing things that are not there), moodiness,
sudden and/or extreme changes in mood, depression, and/or unusual
behavior such as depressed behavior or highly agitated or manic
behavior.
Any condition meeting this definition is a mental or nervous
disorder no matter what the cause of the condition may be; but
medical conditions that are caused by your behavior that may be
associated with these mental conditions (e.g., self-inflicted
injuries) and treatment of severe mental disorders are not subject
to plan limitations that apply to mental or nervous disorders
(See definition of Severe Mental Illness).
|
| Negotiated Rate/Network Rate |
Negotiated Rate or Network Rate is the amount Participating
Providers agree to accept as payment in full for covered services.
It is usually lower than their normal charge. These rates are determined
by the Anthem Blue Cross Prudent Buyer Plan Participating Provider
Agreements. |
| Physician |
- A doctor of medicine (M.D.) or a doctor of osteopathy (D.O.)
who is licensed to practice medicine or osteopathy where the
care is provided, or
- One of the following providers, but only when the provider
is licensed to practice where the care is provided, is rendering
a service within the scope of that license, is providing a service
for which benefits are specified in the Blanket Benefit Agreement,
and when benefits would be payable if the services were provided
by a physician as defined above:
- A dentist (D.D.S.)
- An optometrist (O.D.)
- A dispensing optician
- A podiatrist or chiropodist (D.P.M., D.S.P. Or D.S.C.)
- A licensed psychologist
- A chiropractor (D.C.)
- An acupuncturist (but only for acupuncture and for no
other services)
- A licensed nurse practitioner
- A licensed registered nurse
- A licensed nurse midwife
- A certified registered nurse anesthetist (C.R.N.A)
- A clinical social worker (C.S.W. Or L.C.S.W.)*
- A marriage, family and child counselor (M.F.C.C.)*
- A physical therapist (P.T. or R.P.T.)*
- A speech pathologist*
- An audiologist*
- An occupational therapist (O.T.R.)*
- A respiratory care practitioner (R.C.P.)*
- A psychiatric mental health nurse (R.N.)
- A Registered Dietician (R.D.) for provision of diabetic
medical nutrition therapy only.
Note: The providers indicated by asterisks (*) are covered only
by referral of physician as defined above.
|
| Premium |
The rate you pay to be enrolled in the insurance plan. |
| Reasonable Charge |
A charge considered not to be excessive based on the circumstances
of the care provided including:
- level of skill or experience involved;
- the prevailing or common cost of similar services or supplies;
and
- any other factors that determine value.
|
| Severe mental illness |
As defined by the American Psychiatric Association
in the Diagnostic and Statistical Manual (DSM), severe mental illness
includes the following diagnoses: schizophrenia; schizoaffective
disorder; bipolar disorder (manic-depressive illness); major depressive
disorders; panic disorders; obsessive-compulsive disorder; pervasive
developmental disorder or autism; anorexia nervosa; and bulimia
nervosa. Benefits for severe mental disorders will be provided according
to the plan benefits for mental conditions. |
| Sickness |
A sudden, serious, or unexpected illness, which requires
immediate care for the relief of severe pain or diagnosis and treatment
of such condition. |
| Year or calendar year |
A 12 month period starting January 1 at 12:01 Pacific
Standard Time. |
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