- Industry: Health care
- Number of terms: 4240
- Number of blossaries: 0
- Company Profile:
The Blue Cross Blue Shield Association (BCBSA) is a federation of 39 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans.
A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.
Industry:Health care
Maximum dollar amounts set by MCOs that limit the total amount the plan must pay for all healthcare services provided to a subscriber per year or in his/her lifetime.
Industry:Health care
Identification cards issued by a pharmacy benefit management plan to plan members. These cards assist PBMs in processing and tracking pharmaceutical claims. Also known as drug cards or prescription cards.20
Industry:Health care
Criteria that, if unmet, will cause an automated claims processing system to "kick out" a claim for further investigation.
Industry:Health care
Requirements, sometimes relating to group characteristics or financing measures, that MCOs at times impose in order to provide healthcare coverage to a given group and which are designed to balance a health plan's knowledge of a proposed group with the ability of the group to voluntarily select against the plan (antiselection).
Industry:Health care
The tendency of people who have a greater-than-average likelihood of loss to seek healthcare coverage to a greater extent than individuals who have an average or less-than-average likelihood of loss. Also known as adverse selection.
Industry:Health care
The MCO committee that develops, updates, and administers the MCO's formulary and regularly reviews reports on clinical trials, drug utilisation reports, current and proposed therapeutic guidelines, and economic data on drugs.
Industry:Health care
The use of computer networks to perform business transactions and to facilitate the delivery of healthcare and non-clinical services to an MCO's members.
Industry:Health care
A coding inconsistency that involves using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider.
Industry:Health care
Legislation designed to protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies. See also Sherman Antitrust Act, Clayton Act, and Federal Trade Commission Act.
Industry:Health care
