HealthyBlue 2.0/HealthyBlue Advantage Member ... - CareFirst

Definition of TermsHealth Maintenance Organization (HMO):An organization that provides a wide range ofhealth care services through a PCP who rendersor coordinates all of your care to provide you withquality service while reducing medical costs.HIPAA:Health Insurance Portability and AccountabilityAct. This Act addresses many tenets of healthinsurance coverage including the handling ofPersonal Health Information (PHI) and theMember’s ability to receive credit towards his orher waiting period.Indemnity:Traditional insurance plans under which the healthplan reimburses the provider and the member ona fee-for-service basis after the patient has satisfiedany applicable deductible. These plans typicallyhave the highest out-of-pocket expenses, but theygive you the flexibility to seek treatment from anycovered provider.In-Network:A physician, health care professional or healthcare facility that has contracted with CareFirstBlueChoice, Inc. to render Covered Services toMembers.Member:An individual who meets all applicable eligibilityrequirements stated in Part 2 of the Evidence ofCoverage, is enrolled for coverage, and for whomwe receive the premiums and other requiredpayments. A member can be either a subscriber ora dependent.Preventive Health Care:Care provided to prevent disease or itsconsequences. It includes programs aimed atwarding off illnesses (e.g., immunizations),early detection of disease and inhibiting furtherdeterioration of the body. This includes thepromotion of health through altering behavior,especially by health education.Primary Care Provider:A CareFirst BlueChoice provider selected by or onbehalf of, the member to provide primary care andto coordinate and arrange other required services.Provider:An individual, institution or organization thatprovides medical services. Examples of providersinclude physicians, therapists, hospitals and homehealth agencies.Referral:A written authorization by the PCP for the memberto see a specialty provider.Specialist:A licensed health care provider to whom a membercan be referred to by a PCP.Subscriber:A member who is covered under the Plan as aneligible employee or member of the group, ratherthan as a dependent or the Member to whom theEvidence of Coverage/Agreement is issued.Out-of-NetworkA health care provider or facility that has notcontracted with CareFirst BlueChoice, Inc. toprovide Covered Services to Members.Practitioner:Professionals who provide health care services.Practitioners are required to be licensed asdefined by law.HealthyBlue Member Handbook39