Helpful Definitions
Actual Charge
The amount a physician or supplier actually bills for a particular medical service or supply.

Approved Amount
The amount Medicare determines to be reasonable for a service that is covered under Part B of Medicare. It may be less than the actual charge. For many services, including physician services, the approved amount is taken from a fee schedule that assigns a dollar value to all Medicare-covered services that are paid under that fee schedule.

An arrangement whereby a physician or medical supplier agrees to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. Medicare usually pays 80% of the approved amount directly to the physician or supplier after the beneficiary meets the annual Part B deductible of $100. The beneficiary pays the other 20 percent.

Is the approval by your Medical Group of a referral made by your Primary Care Physician. It is also the approval of your Primary Care Physician or Medicare Group in an emergency.

Benefit Period
A benefit period is a way of measuring a beneficiary's use of hospital and skilled nursing facility services covered by Medicare. A benefit period begins the day the beneficiary is hospitalized. It ends after the beneficiary has been out of the hospital or other facility that primarily provides skilled nursing or rehabilitation services for 60 days in a row. If the beneficiary is hospitalized after 60 days, a new benefit period begins, most Medicare Part A benefits are renewed, and the beneficiary must pay a new inpatient hospital deductible. There is no limit to the number of benefit periods a beneficiary can have.

Benefit Period (Part A)
As defined by Medicare, this begins when you first enter a hospital or skilled nursing facility. It ends when you have been discharged, and not readmitted to a hospital or other facility for at least 60 consecutive days.

The Centers for Medicare and Medicaid Services is the federal government agency responsible for administering Medicare and federal participation in Medicaid. (Formerly known as the Health Care Financing Administration)

The portion or percentage of the Medicare-approved amount that a beneficiary is responsible for paying.

Contracting Hospital
A hospital which has a Blue Cross Senior Secure plan Agreement in effect at the time services are rendered and which is also Medicare certified.

The amount of payment indicated in the Summary Of Benefits section of your contract book. It is due and payable (at the time of service) by the Member to the Medical Group, hospital or other provider of care.

Covered Services
Medically necessary services or supplies which are listed in the Summary Of Benefits section of this Agreement, and for which the member is entitled to receive benefits.

Custodial Care
Care provided primarily to meet the personal needs of the member. This includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administered, or any other care which does not require the continuing services of medical personnel.

The amount of expense a beneficiary must first incur before Medicare begins payment for covered services.

Drugs, Formulary
Drugs which the medical literature indicates are clinically effective, safe and of reasonable cost. The goal of Blue Cross' formulary list of prescription drugs, as established for the WellPoint Pharmacy Plan, is to identify and promote prescription drugs which are therapeutically appropriate and cost effective.

Drugs, non-formulary
Prescription drugs not on Blue Cross' formulary list.

Durable Medical Equipment
Equipment which can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a contracting physician for use in the home. Examples are oxygen equipment, wheelchairs and hospital beds. These items are covered in accordance with Medicare laws, regulations and guidelines.

A sudden, serious or unexpected acute illness, injury or condition which could permanently endanger your health if medical treatment is not received immediately.

Excess Charge
The difference between the Medicare-approved amount for a service or supply and the actual charge, if the actual charge is more than the approved amount.

Experimental Procedures
Procedures that are mainly limited to laboratory and/or animal research, but which are not generally accepted as proven and effective procedures within the organized medical community. When making a determination as to whether a service is experimental, Blue Cross Senior Secure will use Medicare guidelines or rely upon determinations already made by Medicare. Experimental procedures and items are not covered under Blue Cross Senior Secure.

HMO (Health Maintenance Organization)
An organization that provides a wide range of comprehensive health care services through a designated group, or network of doctors, hospitals, labs and other providers. To receive benefits, the member must see the doctor he selects as his primary care physician first for care or a referral, except in the case of an emergency. The choice of doctors is restricted to those in the network.

Home Health Agencies and Visiting Nurse Associations
These are home health care providers, licensed according to state and local laws, to provide skilled nursing and other services on a visiting basis in the Member's home. They must be approved as home health care providers under Medicare and the Joint Commission on Accreditation of Hospitals.

An organization or agency, certified by Medicare, that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people and their families.

Hospitals, non-Contracting
Hospitals that are not part of the Blue Cross Prudent Buyer network and that have not signed a standard contract with Blue Cross.   Blue Cross does not pay benefits for services provided by non-contracting hospitals except in the case of a medical emergency.

IPA (Independent Practice Association)
A partnership, association, or corporation that delivers or arranges for the delivery of health services and which has entered into a contract with health professionals, a majority of whom are licensed to practice medicine or osteopathy.

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

Limited Fee Schedule
A list of maximum amounts Blue Cross will pay for certain services provided by non-network providers. The member is responsible for paying the co-insurance and any amount over the limited fee schedule.

Limiting Charge
The maximum amount a physician may charge a Medicare beneficiary for a covered physician service if the physician does not accept assignment of the Medicare claim. The limit is 15 percent above the fee schedule amount for non-participating physicians. Limiting charge information appears on Medicare's Explanation of Medicare Benefits (EOMB) form.

Under Blue Cross Senior Secure, means the member is "locked-in" to the use of Blue Cross Senior Secure providers. The member must receive all medical care from Contracting Blue Cross Senior Secure Providers, except: emergency services, urgently needed services outside of the Blue Cross Senior Secure service area, such as referral to a specialist or to a non-contracting provider; out of area renal dialysis; or the Choices Plus Self-Referral Benefit. The use of non-contracting providers, except as stated above, will result in the obligation to pay for routine care. Neither Blue Cross Senior Secure nor Medicare will pay for these services.

Medicare Carrier
An insurance organization under contract to the federal government to process Medicare Part B claims from physicians and other suppliers. The names and addresses of the carriers and areas they serve are listed in the back of The Medicare Handbook, available from any Social Security Administration office.

Medicare Hospital Insurance
This is Part A of Medicare. It helps pay for medically necessary inpatient care in a hospital, skilled nursing facility or psychiatric hospital, and for hospice and home health care.

Medical Group
A group of physicians, organized as a legal entity, which has an Agreement in effect with Blue Cross Senior Secure to furnish medical care to Members. INDEPENDENT PRACTICE ASSOCIATION (IPA) is a Participating Medical Group but with the following differences: The Primary Care Physicians are located at various addresses throughout a geographically close area; the Physician's relationship with the IPA administrator is that of an independent contractor. The Member is required, at the time of enrollment, to select a Medical Group to provide services covered under this Agreement. However, in the event the Member does not indicate his or her selection on the enrollment form, Blue Cross Senior Secure will assign the Member to a Medical Group nearest to the Member's residence.

Medically Necessary
Services or supplies are those Blue Cross Senior Secure determines to be:

  1. Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition, and provided for the diagnosis or direct care and treatment of medical condition;
  2. Within standards of good medical practice within the organized medical community;
  3. Not primarily for the convenience of the Member, the Member's physician, or another provider;
  4. The most appropriate supply or level of service which can safely be provided. For Hospital stays, this means that acute care as a bed patient is needed due to the kind of services the Member is receiving or the severity of the Member's condition, and that safe and adequate care cannot be received as an outpatient or in a less intense medical setting.

Medicare Medical Insurance
This is Part B of Medicare. This part helps pay for medically necessary physician services and many other medical services and supplies not covered by Part A.

Mental or Nervous Disorders
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 (for example seeing or hearing things that are not there), moodiness, sudden and/or unusual behavior such as depressed behavior. Some mental or nervous disorders are: schizophrenia, manic depressive and other conditions usually classified in the medical community as psychosis: drug, alcohol or other substance addiction or abuse: depressive phobic, manic and anxiety conditions ( including panic disorder); bipolar affective disorders including mania and depression; obsessive compulsive disorder; hypochondria; personality disorders ( including paranoid, schizoid, dependent, anti-social and borderline); dementia and delirious states; post traumatic stress disorder, hyperkinetic syndromes (including attention deficit disorders); adjustment reactions; reactions to stress; anorexia nervosa and bulimia. Any condition meeting this definition is a mental or nervous disorder no matter what the cause. However, medical conditions that are caused by behavior of the Member that may be associated with these mental conditions (for example self-inflicted injuries) are not subject to these limitations.

Negotiated Fee
The discounted rates that Blue Cross Prudent Buyer network doctors and hospitals agree to charge for covered expenses.

The term used for services received from doctors, hospitals and other providers contracting with Blue Cross to provide care at the negotiated fee and to handle the paperwork.

Non-Contracting Provider
A licensed provider who has not signed an Agreement with Blue Cross Senior Secure to furnish care for Blue Cross Senior Secure Members

The term used for services received from doctors, hospitals or to the provider that are not part of the Blue Cross network. You pay substantially more for out-of-network services.

The most you pay for covered expenses during the year before the plan begins paying 100% of covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out-of-network doctor's services do not count.

Participating Physician and Supplier
A physician or supplier who agrees to accept assignment on all Medicare claims.

Participating Prudent Buyer Physician
A physician who has a Prudent Buyer Plan Participating Physician Agreement in effect with Blue Cross of California at the time services are rendered.

Permanent Absence
A permanent absence is an uninterrupted absence of more than 6 months outside the Blue Cross Senior Secure service area. If you move or travel and do not intend to return to the Blue Cross Senior Secure Service Area within 6 months, it is considered a permanent move and you must notify Blue Cross Senior Secure.

PMG (Participating Medical Group)
A group of doctors both primary care physicians and specialists, who are in practice together and provide health care services.

PPO (Preferred Provider Organization)
Health care providers who are under contract to provide care at discounted or fixed fees. Unlike HMOs, health plans with a PPO allow the member to choose any doctor at any time. However, if the member selects a non-PPO provider he will pay more out of pocket for services than he would if he selected a PPO "network" provider.

Pre-existing Condition or Pre-existing Waiting Period
If the member receives medial advice, or treatment was recommended or received for any accident, illness, or other medical condition during six months before he enrolled in a Blue Cross plan, he won't be covered for the care he receives as a result of that condition until he has been enrolled in the Blue Cross plan for six months. If he satisfied the six-month waiting period while enrolled in another medical plan, and enrolled with Blue Cross within 30 days of completing that waiting period, he won't need to complete another pre-existing waiting period. He will receive partial credit if he was insured under another plan for less than six months.

Primary Care Physician
A physician who is a member of a Medical Group that the Member has selected to provide health care. A Primary Care Physician is responsible for authorizing, coordinating and controlling the delivery of covered services to the Member. Primary Care Physicians include general and family practitioners, internists and such other specialists as Blue Cross Senior Secure may approve to be designated a Primary Care Physician.

Prior Authorization
A system whereby a provider must receive approval from a staff member of the health plan, such as the health plan Medical Director, before a member can receive certain health care services.

Psychiatric Health Facility
An acute 24-hour facility as defined in California Health and Safety Code 1230.2. It must be :

  1. Licensed by the Department of Health Services; 
  2. Qualified to provide short-term inpatient treatment according to the State law;
  3. Accredited by the Joint Commission on Accreditation of Health Care Organizations; 
  4. Staffed by an organized medical or professional staff which includes a physician as a Medical Director.

Qualifying Prior Coverage
Any individual or group plan that provides medical, hospital, and surgical coverage, including continuation or conversion coverage or coverage under a publicly sponsored program such as Medicare or Medicaid. It does not include accident only, credit, disability income, Medicare supplement, long term care insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans.

Any request for authorization by the Primary Care Physician to the Medical Group for covered specialty services or hospitalization. This may also require utilization review by the Medical Group.

Service Area
A geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which a Medicare+Choice eligible individual may enroll in a particular Medicare+Choice Plan offered by a Medicare+Choice Organization. This is the area within which you generally must get non-emergency and urgently needed services other than dialysis.

Skilled Nursing Care
Refers to services that can only be performed by, or under the supervision of, licensed nursing personnel.

Skilled Nursing Facility
Provides skilled nursing care, continuous 24-hour nursing service, and maintains daily medical records for each patient. It must be licensed under all applicable state and local laws. It must be approved for payment of Medicare benefits or be qualified to receive that approval if so requested. It does not include any home or facility used primarily for rest, educational care, treatment of mental or nervous disorders or a facility for the aged which furnishes primarily custodial care, including training in routines of daily living.

Temporary Absence
A temporary absence from the Service Area is an absence of 6 months or less outside the Blue Cross Senior Secure service area. If the member moves or travels and does not intend to return to the Blue Cross Senior Secure Service Area within 6 months, it is considered a permanent move and the member must notify Blue Cross Senior Secure.

Urgently Needed Services
Services needed immediately as a result of an unforeseen illness, injury, or condition; and it is not reasonable given the circumstances to get the services through your Primary Care Physician or other plan providers. Ordinarily, these services are provided when you are out of the service area. In extraordinary cases, these are services provided when you are in the service area but plan providers are not available.

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Anthem Blue Cross

Oleg Skurskiy Authorized Independent Agent for Anthem Blue Cross (in California), Anthem Blue Cross and Blue Shield (in Colorado, Connecticut, Nevada and New Hampshire) and Blue Cross Blue Shield of Georgia. Independent licensees of the Blue Cross Blue Shield Association

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