Choose a letter
of the the alphabet to jump to that section of the glossary.
Please wait for the entire page to load before making your selection.
A | B | C | D
| E | F | G | H
| I | M | N | P
| R | S | T | U
| W | Y
ACCIDENTAL INJURY
A traumatic injury to you caused solely by an accident. The injury must occur
while you are covered by the plan.
ALTERNATIVE BENEFITS
A benefit program that gives you and your family an alternative to lengthy hospitalizations.
It is designed to provide the patient with the best environment for recovery
and in the most cost effective setting. Also known as "Comprehensive Managed
Care" and "Individual Case Management."
APPLICATION
The subscriber's original application form and any written supplemental application
we accept.
ASSISTED REPRODUCTIVE TECHNOLOGY
(ART)
Any combination of chemical and/or mechanical means of obtaining gametes and
placing them into a medium (whether internal or external to the human body)
to enhance the chance that reproduction will occur. Examples of ART include,
but are not limited to, in vitro fertilization, gamete intrafallopian transfer,
zygote intrafallopian transfer and pronuclear stage tubal transfer.
BLUE CROSS
Blue Cross and Blue Shield of Alabama.
BLUECARD PROGRAM
An arrangement among Blue Cross Plans by which a member of one Blue Cross Plan
receives benefits available through another Blue Cross Plan located in the area
where services occur.
CERTIFICATION OF MEDICAL NECESSITY
The written results of our review using recognized medical criteria to determine
whether a member requires treatment in the hospital before he is admitted, or
within 48 hours of the next business day after the admission in the case of
emergency admissions. Certification of medical necessity means only that a hospital
admission is medically necessary to treat your condition. Certification of medical
necessity does not mean that your group has paid us all monies due for you.
Certification of medical necessity does not consider whether your admission
is excluded by this plan.
CHARGE
The reasonable charge not exceeding the provider's actual charge regularly and
customarily made for those services or supplies. For services or supplies furnished
to a member by a Preferred Provider, "charge" means the amount for
those services or supplies which Blue Cross has agreed upon with the Preferred
Provider. In the case of services or supplies for which a usual, customary and
reasonable fee exists (other than a Preferred Provider) the charge will be the
UCR fee.
CONCURRENT UTILIZATION REVIEW
PROGRAM (CURP)
A program designed to promote the most efficient and effective use of health
care resources while utilizing cost effective methods to administer hospitalization.
CONTRACT
The Group Health Benefits contract between your Group and Blue Cross and Blue
Shield of Alabama. The contract is made up of (1) your Group's Group Application
for the contract; (2) this Summary Plan Description; and (3) any written change
to this Summary Plan Description. Your contract number is listed on your I.D.
card.
CONTRACT EFFECTIVE DATE
The date the Group Health Benefits contract becomes effective; the same date
we accept the Group Application.
COSMETIC SURGERY
Any surgery done primarily to improve or change the way one appears, cosmetic
surgery does not primarily improve the way the body works or correct deformities
resulting from disease, trauma or birth defect. For important information on
cosmetic surgery, see the "Exclusions" section.
CUSTODIAL CARE
Care primarily to provide room and board for a person who is mentally or physically
disabled.
DURABLE MEDICAL EQUIPMENT
Equipment we approve as medically necessary to diagnose or treat an illness
or injury or to prevent a condition from becoming worse. To be durable medical
equipment an item must be made to withstand repeated use, be for a medical purpose
rather than for comfort or convenience, be useful only if you are sick or injured,
and be related to your condition and prescribed by your physician to use in
your home.
EFFECTIVE DATE
The date on which the coverage of each individual subscriber and dependent begins
as listed in Blue Cross's records.
ELIGIBLE PERSON
Any employee or member of the group or other person who meets the eligibility
standards of their plan and is designated as eligible to us by the group.
FAMILY COVERAGE
Coverage for a subscriber and one or more dependents.
GROUP
The employer, association, or other entity which contracts with Blue Cross and
through which you have coverage.
GROUP APPLICATION
The document in which the employer applies to us for a group benefits plan.
HOME HEALTH CARE AGENCY
A Preferred or a Non-Preferred Home Health Care Agency.
HOSPICE
A Preferred or a Non-Preferred hospice.
HOSPITAL
A Participating or a Non-Participating Hospital as defined in this plan.
INDIVIDUAL CASE MANAGEMENT
Benefits which are an alternative to more expensive covered benefits. They provide
the patient with the best environment for recovery and in the most cost-effective
setting. Also known as "Comprehensive Managed Care."
INPATIENT
A registered bed patient in a hospital.
INVESTIGATIONAL
Any treatment, procedure, facility, equipment, drugs, drug usage, or supplies
that either we have not recognized as having scientifically established medical
value, or that does not meet generally accepted standards of medical practice.
MEDICAL EMERGENCY
A medical condition that occurs suddenly and without warning with symptoms which
are so acute and severe as to require immediate medical attention to prevent
permanent damage to the health, other serious medical results, serious impairment
to bodily function, or serious and permanent lack of function of any bodily
organ or part.
MEDICALLY NECESSARY OR MEDICAL
NECESSITY
Services or supplies which are necessary to treat your illness, injury, or symptom.
To be medically necessary, services or supplies must be determined by Blue Cross to be:
A "setting" may be your home, a physician's office, a Participating Ambulatory Surgical Facility, a hospital's outpatient department, a hospital when you are an inpatient, or another type of facility providing a lesser level of care. Only your medical condition is considered in deciding which setting is medically necessary. Your financial or family situation, the distance you live from a hospital or other facility, or any other non-medical factor is not considered. As your medical condition changes, the setting you need may also change. Ask your physician if any of your services can be performed on an outpatient basis, or in a less costly setting.
MEMBER
A subscriber or eligible dependent who has coverage under the contract. The
term member also refers to a former dependent or subscriber who was not terminated
for gross misconduct, who is eligible for and covered under COBRA.
MENTAL AND NERVOUS DISORDERS
These are mental disorders, mental illness, psychiatric illness, mental conditions
and psychiatric conditions. These disorders, illnesses and conditions are considered
mental and nervous disorders whether they are of organic, biological, chemical,
or genetic origin. They are considered mental and nervous disorders however
they are caused, based or brought on. Mental and nervous disorders include,
but are not limited to psychoses, neuroses, schizophrenic-affective disorders,
personality disorders, and psychological or behavioral abnormalities associated
with temporary or permanent dysfunction of the brain or related system of hormones
controlled by nerves. They are intended to include disorders, conditions, and
illnesses listed in DSM-III or DSM-IV (Diagnostic and Statistical Manual of
Mental Disorders).
NON-PARTICIPATING HOSPITAL
Any hospital (other than a Participating Hospital) that has been approved by
the Alabama Hospital Association or the American Hospital Association as a "general"
hospital or meets the requirements of the American Hospital Association for
registration or classification as a "general medical and surgical"
hospital. "General" hospitals do not include those that are classified
or could be classified under standards of the American Hospital Association
as "special" hospitals. Examples of these "special" hospitals
are those classified for psychiatric, alcoholism and other chemical dependency,
rehabilitation, mental retardation, chronic disease or any other specialty.
"General" hospitals also do not include facilities primarily for convalescent
care or rest or for the aged, school or college infirmaries, sanatoria, or nursing
homes.
NON-PARTICIPATING PHARMACY
Any pharmacy which is not a Participating Pharmacy.
NON-PREFERRED HOME HEALTH CARE
AGENCY
Any home health care agency which is not a Preferred Home Health Care Agency.
NON-PREFERRED HOSPICE
Any hospice which is not a Preferred Hospice.
PARTICIPATING AMBULATORY SURGICAL
FACILITY
Any facility with which Blue Cross has a Participating Ambulatory Surgical Facility
contract for furnishing health care services.
PARTICIPATING HOSPITAL
Any hospital with which Blue Cross has a contract for furnishing health care
services.
PARTICIPATING PHARMACY
Any pharmacy with which Blue Cross or its subsidiary, Preferred Care Services,
Inc., has a contract for dispensing prescription drugs.
PARTICIPATING RENAL DIALYSIS FACILITY
Any free-standing hemodialysis facility with which Blue Cross has a contract
for furnishing health care services.
PARTICIPATING SUBSTANCE ABUSE
FACILITY
Any facility in the state of Alabama with which Blue Cross has a contract for
the furnishing of residential and/or outpatient substance abuse rehabilitation
services.
PHYSICIAN
One of the following when licensed and acting within the scope of that license
at the time and place you are treated or receive services: Doctor of Medicine
(M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor
of Medical Dentistry (D.M.D.), Doctor of Chiropractic (D.C.), Doctor of Podiatry
(D.P.M.), Doctor of Optometry (O.D.), and Psychologist (Ph.D. or Psy.D.), as
defined in Section 27-1-18 of the Alabama Code. PLAN: This Summary Plan Description
describing the benefits of your Employee's Health Benefits Plan.
PREADMISSION CERTIFICATION AND
POSTADMISSION REVIEW
The procedures used to determine whether a member requires treatment as a hospital
inpatient prior to a member's admission, or within 48 hours or the next business
day after the admission in the case of an emergency admission, based upon medically
recognized criteria.
PREFERRED CARE
A program whereby providers have agreements with Blue Cross to furnish certain
medically necessary services and supplies according to an agreed upon fee schedule
for medical and surgical procedures, certain services and supplies to members
entitled to benefits under the Preferred Care Program.
PREFERRED HOME HEALTH CARE AGENCY
Any home health care agency in Alabama with which Blue Cross has a contract.
PREFERRED HOME HEALTH CARE FEE
SCHEDULE
The schedule of procedures and the fee amounts listed in the Preferred Home
Health Care Fee Schedule or the amount of the Preferred provider's actual charge,
whichever is less for Preferred Home Health Care Benefits.
PREFERRED HOSPICE
Any hospice in Alabama with which Blue Cross has a contract.
PREFERRED MEDICAL DOCTOR OR PREFERRED
PHYSICIAN
A physician who has an agreement with Blue Cross to provide surgical and medical
services to members entitled to benefits under the PMD Program or another Preferred
Care Program through a contract with Blue Cross.
PREFERRED PROVIDER OR PARTICIPATING
PROVIDER
Any provider of health care services or supplies (such as a Preferred Physician,
Preferred Medical Laboratory, Preferred Radiology Provider, or Preferred Outpatient
Facility) who has an agreement with Blue Cross to furnish services or supplies
to members entitled to benefits under the Preferred Care Program.
PREFERRED RADIOLOGY PROVIDER OR
PRP
Any provider with which Blue Cross and Blue Shield of Alabama has a contract
for the furnishing of diagnostic radiology procedures such as computerized axial
tomography (CAT scan) and magnetic resonance imaging (MRI scan).
PREGNANCY
The condition of and complications arising from a woman having a fertilized
ovum, embryo or fetus in her body-usually, but not always, in the uterus-and
lasting from the time of conception to the time of childbirth, abortion, miscarriage
or other termination.
PRIVATE DUTY NURSING
Nursing care provided in the patient's home by a licensed professional nurse
(R.N.) or a licensed practical nurse (L.P.N.) who does not reside in the patient's
home and is not related to the patient by blood or marriage.
PMD FEE AMOUNT PAYABLE
The amount that will be paid to a Preferred Physician or other Preferred Provider.
It is the fee for a procedure listed in the PMD Fee Schedule or the amount of
the Preferred Provider's actual charge, whichever is less.
PMD FEE SCHEDULE
The schedule of medical and surgical procedures and the fee amounts for those
procedures under the Preferred Medical Doctor program and other Preferred Provider
programs as applicable.
RADIOLOGY SCHEDULE
The schedule of radiological procedures which is on file and available for examination
at the Birmingham offices of Blue Cross.
SUBSCRIBER
The employee, retiree, or COBRA member whose application for coverage under
the contract is made and accepted by Blue Cross and the Employer.
SUBSTANCE ABUSE
The uncontrollable or excessive abuse of addictive substances, such as (but
not limited to) alcohol, drugs or other chemicals and the resultant physiological
and/or psychological dependency which develops with continued use.
TELECONSULTATION
Consultation, evaluation and management services provided to patients via telecommunication
systems without personal face-to-face interaction between the patient and healthcare
provider.
UCR (USUAL, CUSTOMARY AND REASONABLE
FEE)
That part of a provider's charge that we will allow as covered expenses. The
usual, customary and reasonable value of the provider's service is based on
historical data developed from the following criteria:
The UCR allowance will not exceed the amount the provider charges.
WE, US, OUR
Blue Cross and Blue Shield of Alabama.
YOU, YOUR
The subscriber or member as shown by context.
This site
and all contents are Copyright 2009 by Blue Cross and Blue Shield of Alabama,
an Independent Licensee of the Blue Cross and Blue Shield Association.