HealthyBlue 2.0/HealthyBlue Advantage Member ... - CareFirst

Definition of TermsAllowed Benefit:The maximum dollar amount allowed for servicescovered, regardless of the provider’s actual charge.A provider who participates in the network cannotcharge the member more than this amount for anycovered service.Appeal:A protest filed by a member or a health careprovider under CareFirst BlueCross BlueShield/CareFirst BlueChoice’s internal appeal processregarding a coverage decision.Authorization:The contractual requirement that the provider ormember notify and obtain approval from the planbefore certain services are covered for a member.Authorization is required for services such as, butnot limited to, non-emergency hospitalizations,certain outpatient hospital services, skilled nursingcare, home health care, outpatient surgicalservices, and durable medical equipment.Balance Billing:The practice of billing a member for the differencebetween the Allowed Benefit and the actual charge.CareFirst BlueChoice Service Area:CareFirst BlueChoice’s Service Area is a clearlydefined geographic area in which CareFirstBlueChoice has arranged for the provision ofhealth care services to be generally availableand readily accessible to Members. CareFirstBlueChoice will provide the Member with aspecific description of the Service Area at the timeof enrollment. The Service Area is as follows: TheDistrict of Columbia; the state of Maryland; and,in the state of Virginia, the cities of Alexandria andFairfax, Arlington County, the town of Vienna andthe areas of Fairfax and Prince Williams Countieslying east of Route 123.Claim Form:A form obtained from Member Services forreimbursement of covered services paid by themember.Coinsurance:means the percentage of the Allowed Benefitallocated between CareFirst BlueChoice and theMember whereby CareFirst BlueChoice and theMember share in the payment for covered services(e.g., 20 percent for lab services or X-rays).Complaint:A protest filed with the regulatory departmentinvolving an adverse decision, coverage decision,appeal decision, or grievance decision.Coordination of Benefits:A provision which determines the order of benefitdetermination when a member has health carecoverage under more than one plan.Copayment (Copay):The dollar amount that a member must pay forcertain covered services.Deductible:The dollar amount of incurred covered expensesthat the member must pay before CareFirstBlueChoice makes payment.Dependent:A member who is covered under the Plan as thespouse, domestic partner or eligible child of aSubscriber.Evidence of Coverage/Agreement:A document reflecting an individual’s or group’sagreement for health care coverage with CareFirstBlueChoice.Exclusions:Specific conditions, treatments, services orcircumstances listed in the contract for whichCareFirst BlueChoice will not provide benefits.Health Care Provider:An individual who is licensed or otherwiseauthorized in this State to provide health careservices in the ordinary course of business orpractice of a profession, and is a treating providerof the member; or a hospital, facility or other entitylicensed to provide health care services.38 HealthyBlue Member Handbook