Personal Comp Member Handbook - CareFirst BlueCross BlueShield

Definition of TermsAppeal: A protest filed by a member or a health careprovider under CareFirst’s internal appeal processregarding a coverage decision.Claim Form: A form obtained from Member Servicesfor reimbursement of covered services paid by themember.Certificate of Creditable Coverage: A documentnecessary to waive any waiting periods, exclusionaryamendments or medical underwriting for a personwith a pre-existing condition.Coinsurance: A percentage of the plan allowance thatthe member pays for a covered service (e.g., 20 percentfor lab services or X-rays).Coordination of Benefits (COB): A provision whichdefines the order of benefit reimbursement when amember has health care coverage under more than oneplan.Copayment: A specified amount that the memberpays for a covered benefit (e.g., $10 per office visit to aphysician).Deductible: The dollar amount of incurred coveredexpenses that the member must pay before the Planmakes payment.Dependent: A member who is covered under thePlan as the spouse or eligible child of a Subscriber.Exclusions: Treatments, services, supplies orcircumstances listed in the contract for which CareFirstwill not provide benefits and specific conditions thatare subject to a 10-month waiting period.Health Care Practitioner: An individual, institution ororganization that provides medical services. Examplesof providers include physicians, therapists, hospitalsand home health agencies.HIPAA: Health Insurance Portability andAccountability Act. This Act addresses many tenetsof health insurance coverage including the handlingof Personal Health Information (PHI) and theMember’s ability to receive credit towards his orher waiting period.Member: An individual who is enrolled for coverage,and for whom we receive the premiums and otherrequired payments. A member can be either asubscriber or a dependent.Network: A group of multi-specialty medical groupsand individual practice doctors who are contractedto provide services to members of a health plan.Participating Provider: A covered provider thatcontracts with CareFirst to be paid directly forrendering covered services to eligible membersof this plan.Policyholder: The individual to whom the policyis issued.Preventive Health Care: Care provided to preventdisease or its consequences. It includes programsaimed at warding off illnesses (e.g., immunizations),early detection of disease and inhibiting furtherdeterioration of the body.30