| 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. |
| Calendar year |
A 12 month period starting January 1 at 12:01 Pacific Standard Time. |
| 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. |
| Plan Year/Benefit Year |
A 12 month period starting August 15 at 12:01am PST and ending the following August 15 at 12:00 am. |
| 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. |
