Injury to the body sustained in an accident.
Is accomplished through successfully passing a review of our business practices against published standards performed by an external certifying agency like NCQA or URAC.
The maximum amount that is payable to you under your health insurance plan for a particular healthcare service. Contracted providers have agreed to accept this amount as payment in full. For example, if the provider charges $100 for a service and Blue KC pays $80 as the allowable charge, the provider cannot ask the member to pay the remaining $20. Keep in mind, however, that some health insurance plans have coinsurance. In those cases, members are required to pay a percentage of the allowable charge. For specific details about your plan, review your certificate or contract.
Annual Enrollment Period
The annual enrollment period determined by an employer and Blue KC when an eligible employee and his or her dependents can enroll for health insurance or make changes to current health insurance coverage.
BlueCard® PPO Program Service Area
The service area of Blue KC and any other service area of a Blue Cross and/or Blue Shield plan participating in the BlueCard® PPO Program. See also BlueCard PPO Program.
Brand Name Drug
A prescription medication that may or may not have a generic equivalent. A generic equivalent cannot be manufactured until the original brand name patent has expired. A brand name drug is a more expensive version of a generic equivalent, if a generic drug exists, see also Tier 2 and Tier 3.
January 1 through December 31 of the same year.
Calendar Year Maximum
The maximum dollar amount or maximum number of days, visits or healthcare sessions that a member has healthcare coverage in one calendar year. If a member exceeds these maximums, no more benefits for such covered services will be provided during the same calendar year. For example, a member’s health insurance plan might cover 26 chiropractic visits a year. The member would have to pay 100% for additional visits.
A case manager typically works with a member receiving in-patient hospital care. The member has to receive a referral to work with a case manager who helps coordinate a member’s care and collaborates with family members and physicians. Case managers recommend programs to help members manage ongoing health conditions and provide supporting educational materials.
A document that outlines the benefits, exclusions, responsibilities, rights and other important information related to a member's group health insurance plan.
The percentage of an allowable charge that a member pays not including any copayments or deductibles. For example, if the member's plan has an 80/20 coinsurance rate, Blue KC will pay 80 percent of the allowable charge for eligible medical expenses and the member will pay the remaining 20 percent.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A law requiring some employers to offer continued health insurance coverage to employees whose coverage was terminated. Learn more about COBRA.
An agreement between an employer and Blue KC that defines the terms of health insurance coverage. Terms include the employer's application to provide coverage to members and the member's application to request to receive coverage. The contract also includes the member’s certificate, which explains a member’s rights and any amendments to that certificate.
Coordination of Benefits (COB)
Coordinating with another health insurance plan to provide payment for healthcare services for a member who is covered under more than one health insurance contract.
The period during which a member has healthcare coverage as a result of the member and/or employer paying premiums on a timely basis.
An individual covered under a health insurance plan provided by or administered by Blue KC. See also member.
Care to help a member perform normal daily activities, such as dressing or eating rather than providing medical treatment.
The process of coordinating and managing the care of a member before he or she is discharged from a medical facility.
Through the Blue KC Healthy Companion™ program, Blue KCmembers, with the exception of FEP members can receive education, tools and other resources to help them manage certain chronic diseases, such as high blood pressure, asthma, chronic obstructive pulmonary disease (COPD) and depression.
Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT) is a system of directly transferring money from one bank account to another without any paper money changing hands.
The determination of a member's qualification for health insurance coverage.
Ambulance services and/or healthcare items and services used to evaluate and treat a member in an emergency medical situation.
Employee Assistance Program (EAP)
A program typically offered by an employer that provides counseling services for subscribers and their eligible dependents to assist with everyday life challenges and stress management. If your employer has arranged for this benefit, log in and click the My Coverage tab to find more information about your EAP.
Explanation of Benefits (EOB)
A statement sent to the member listing healthcare service(s) obtained, amount(s) paid by the plan and the total amount that a member may owe to a provider.
A less expensive drug that is chemically identical to its brand name equivalent but can only be produced after the brand name drug's patent has expired. See also Tier 1.
Health Maintenance Organization (HMO)
A health insurance plan that provides a predetermined medical care benefit package and requires members to use providers in the plan's network to receive benefits. See also HMO provider. If you are an HMO member, you will need to check to see whether a provider is an HMO provider. If a provider is an HMO provider, you will receive your benefits for covered services as outlined in your certificate or contract. If you choose to visit a non-HMO provider, you will not receive any benefits except in the case of an emergency. Please note, whether a provider is participating, non-participating, preferred or non-preferred does not apply to HMO members.
Health Reimbursement Arrangement (HRA)
An HRA is the same thing as a Personal Care Account (PCA). It is commonly used with a high-deductible health plan such as Personal Blue. An HRA is funded by an employer. Members can use money in their HRA to pay for eligible medical expenses. They can roll over any unused funds each year, and employers can establish limits on the rollover amount.
Health Savings Account (HSA)
An account that allows members enrolled in a qualified high-deductible health plan to contribute funds on a tax-free basis into the member's account for payment of qualified medical expenses as defined by the IRS. A member's employer may also contribute funds to the account. Unused funds in an HSA roll over in the member's account at the end of each calendar year. Learn more about Health Savings Accounts.
A service for the prevention, diagnosis and or treatment of a health condition.
An organization that provides medical services such as a chaplain and on call nurse and medical supplies to individuals who are terminally ill.
A facility that provides 24 hour healthcare and nursing services to treat injured and sick patients on an inpatient and outpatient basis.
Initial Enrollment Period (Open Enrollment)
A period of time when an individual is first eligible to enroll for healthcare coverage.
A hospital, pharmacy, physician or other medical service provider that has a contract to participate in one or more plans with Blue KC. A provider who is considered in-network for one plan may be considered out-of-network for another plan.
Cases in which the effectiveness and/or safety of a healthcare service has not been established. Benefits are not available for investigational healthcare services. Please see the Exclusions and Limitations sections of your certificate or contract for more information.
The maximum dollar amount or number of services or visits that Blue KC will cover over the duration of a member’s health insurance policy. Blue KC will not pay for services beyond this maximum.
A federal government program that provides health insurance to anyone ages 65 and older, to anyone with permanent kidney failure and to certain people with disabilities. Medicare consists of four parts:
- Medicare Part A helps cover inpatient care in hospitals and skilled nursing facilities and hospice care.
- Medicare Part B helps cover doctor services and outpatient care.
- Medicare Part C is provided through private insurance companies approved by Medicare that provides lower costs and expanded benefits.
- Medicare Part D may help lower the cost of prescription drugs. Learn more about Medicare Parts A, B and C. Learn more about Medicare Part D.
Member Identification Card (member ID Card)
A member ID card includes the member's name, member and group identification numbers, healthcare plan name, copayment amounts and customer service phone numbers. Members should always have their member ID card with them because it is typically required at every office, hospital and pharmacy visit. To order a temporary or replacement member ID card, log in, click the My Account tab. You can request a temporary card or order a new member ID card.
A hospital, pharmacy, physician or other medical service provider that does not have a contract with Blue KC or another Blue Cross and/or Blue Shield plan to provide healthcare services to members. Depending on the member's plan, services from a non-participating provider may or may not be covered. A non-participating provider is also referred to as an out-of-network provider. PPO members who visit a non-participating provider will receive limited benefits; HMO members will not receive any benefits except in the case of an emergency.
Most benefit plans have an out-of-pocket maximum. If the total dollar amount that you have paid in deductibles, coinsurance, and in some cases copayments, reach this maximum amount in a calendar year, then Blue KC will pay 100% of the allowed charges for the remainder of the year.
Personal Care Account (PCA)
A Personal Care Account is funded by an employer. Members can use money in their PCA to pay for eligible medical expenses. Members can roll over any unused funds each year, and employers can establish limits on the rollover amount.
Preferred Provider Organization (PPO)
A health insurance plan that offers members a preferred network of healthcare providers who provide services for predetermined fees. Members who choose to use an out-of-network provider will generally pay a larger portion of medical expenses. If you are a PPO member, you will need to check to see whether a provider is in-network or out-of-network. Also, check to see whether the provider is participating or non-participating in a Blue KC provider network. All non-participating providers are considered out-of-network. Visiting these types of providers could result in limited benefits.
Primary Care Physician (PCP)
The physician who a member chooses as his or her primary physician for medical care. Primary care physicians typically specialize in one of four fields of medicine: family practice, general practice, internal medicine or pediatrics. HMO members are required to have a PCP on file.
A process that uses utilization review to determine the necessity of a service, admission to a healthcare facility or approval for treatment prior to services being provided. See also concurrent review and utilization review.
The opportunity or requirement to have a second provider review your health status and any proposed healthcare services and/or treatments.
Selected Services Arrangements
An arrangement of certain covered services that must be performed by a specific contracted provider. If services are performed by a provider not listed in the contract, those services will not be covered or will be paid at a lower level.
The geographic area served by Blue KC, which includes 32 counties in the greater Kansas City area and northwest Missouri. In Kansas, Blue KC serves Johnson and Wyandotte counties. In Missouri, we serve Andrew, Atchison, Bates, Benton, Buchanan, Caldwell, Carroll, Cass, Clay, Clinton, Daviess, DeKalb, Gentry, Grundy, Harrison, Henry, Holt, Jackson, Johnson, Lafayette, Livingston, Mercer, Nodaway, Pettis, Platte, Ray, Saline, St. Clair, Vernon and Worth counties. Not all HMO products are available in every Missouri county we serve. Contact Us for information regarding the HMO service area in Missouri.
Skilled Nursing Facility
A facility that provides 24 hour nursing services including rehabilitation and long term illness care.
Special Enrollment Period
The period of time in which an individual who did not initially enroll for coverage may elect to enroll and/or a new dependent may enroll for coverage if specific criteria are met. Members may also elect to make changes to their coverage based on life changes or events such as a marriage or the birth of a child.
Doctors of medicine (MD), osteopathy (D.O.) and other medical practitioners who specialize in a particular branch of medicine. For example a cardiologist, allergist or OB GYN.
The primary member listed on the insurance policy. A subscriber and any of his or her enrolled dependents receive the benefits of a health insurance plan.
Tier 1 (Generic Drug)
A generic drug that contains the same active ingredients as a brand name drug and has the lowest copayment. For example Ranitidine is the generic version of the brand name drug Zantac.
Tier 2 and Tier 3 (Brand Name Drug)
Brand name drugs that have a mid-range copayment option (Tier 2 medications) or the highest copayment option (Tier 3 medications). Tier 3 also includes medications not on a prescription drug list, medications with an available generic equivalent and new drugs that are being reviewed.
A formal review conducted by licensed registered nurses of healthcare services, procedures and/or hospital admissions. The review looks at several aspects of care including determining the medical necessity of in-patient care. See also concurrent review and prospective review.
vCard is a standard that defines the format of an electronic business card. All devices supporting vCard can exchange contact information such as phone numbers and addresses.
The length of time an employee must continuously work for an employer before the employee is eligible for coverage.