MEMBER
Changes are received via computer system for updating addresses, date of births, adding and cancellations for these types of accounts.
What are AEP/Tape groups?
Tool to use before quoting benefits. Provides helpful hints and links to the ABS.
What is Benefit Navigator?
Health Insurance Portability and Accountability Act
What does HIPAA stand for?
An itemized bill for services provided to a member.
What is a claim?
The process by which members or their primary care physicians (PCP) notify the health plan in advance of treatment plans, such as a hospital admission or a complex diagnostic test. Also called pre-notification.
What is a pre-authorization?
This is the first/main system where changes, updates or correction are made regarding membership, eligibility issues.
What is Bluestar?
Covered services that protect against disease or further progression of a disease
What are Preventative Services?
A health plan, a health care clearinghouse, or a health care provider who electronically transmits health information according to the HIPAA standard transactions (i.e., billing, payment, eligibility, etc.). Examples of healthcare providers include; doctors, hospitals, clinics, nursing homes, pharmacies, dentists, chiropractors, etc.
What is a HIPAA Covered Entity?
A form you or your doctor fill out and submit to your health care benefits plan for payment.
What is a claim form?
The process by which members or their primary care physicians (PCP) notify the health plan in advance of treatment, to determine if there is coverage for the service under the plan.
What is a pre-determination?
This is the system that can be used to get a temporary ID card in case the member has not received their permanent card for a medical visit.
What is BAM-Blue Access for Members?
A period of time each year when consumers can purchase or change health care coverage for the upcoming year.
What does Open Enrollment Period mean?
The release, transfer, provision of, access to, or divulging in any manner of information
What is a disclosure?
A service that is covered according to the terms in your health care benefits plan.
What is a covered service?
An exception made for a member to see an out of network provider at an in network level. This could be due to a network limitation or continuation of care.
What is a PPO Waiver?
This form can be used to show proof of prior insurance coverage and is available once the policy is cancelled/terminated with the insurance carrier
What is COCC? Certificate of Credible Coverage?
The amount you are required to pay annually before reimbursement by your health care benefits plan begins.
What is the deductible?
A key requirement of federal and state privacy laws requiring reasonable efforts be taken to limit the use, disclosure, or access to PII which includes PHI, SPI and CPI to accomplish the intended purpose or function. HCSC applies this concept to all data uses and disclosures including BCI. HCSC Corporate Privacy Policy/Procedure #7 provides more information.
What is the Minimum Necessary rule?
Is created after a claim payment has been processed by your health care plan. It explains the actions taken on a claim such as the amount that will be paid, the benefit available, discounts, reasons for denying payment and the claims appeal process. It is available both as a paper copy and online.
What is an Explanation of Benefits (EOB)?
The systems use to view pre-authorizations, PPO Waivers, or pre-determinations.
What are ARIS and Aerial?
The letters included on a member’s id card that indicates the State/Home plan of the account/membership
What is the Alpha Prefix?
The maximum amount a health care plan will reimburse a doctor or hospital for a given service.
What is the allowed amount?
Any data that uniquely identifies an individual. The definition varies in federal and state laws, as well as HCSC government and customer contracts. HCSC's definition includes the following categories: Protected Health Information (PHI), State Personal Information (SPI) and Contract Personal Information (CPI) and can be found in the following forms: paper, oral or electronic.
What is PII (Personally Identifiable Information)?
Specific medical conditions or circumstances that are not covered under a health care plan.
What is an exclusion?
The way we review the type and amount of care you're getting. This involves looking at the setting for your care and its medical necessity. Examples may use prior authorization, case management, accompanying reviews or proper discharge planning.
What is Utilization Management?