The extent to which a member of a managed care organization can obtain available services at the time they are needed. This refers to both telephone access and ability to schedule an appointment.
An evaluative process in which a health care organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body and to ensure that the organization meets a specified level of quality.
Include eating, toileting, transferring, bathing, dressing and mobility.
The amount we consider reasonable for a covered service or supply.
The amount we pay for a covered service or supply as shown on your Explanation of Benefits.
Your Certificate of Coverage is the document that describes the services your plan covers, how to file claims, membership guidelines and other terms and conditions of your coverage. It also contains a list of excluded services and supplies.
A fixed dollar amount you must pay for specific services, if any, as shown on your Outline of Coverage.
A percentage of our allowed price you must pay, as shown on your Outline of Coverage, after you meet your deductible.
- your Outline of Coverage;
- your Identification Card; and
- your application and any supplemental applications that you submitted and we approved.
The portion of insurance that a member pays for covered benefits through co-payments, coinsurance, or deductibles.
Describes a service or supply for which you are eligible for benefits under your Contract.
The amount you must pay toward the cost of specific services each calendar year before we make payment. Your Outline of Coverage shows your deductible amounts.
A subscriber’s spouse, the other party to a subscriber’s Civil Union,or a subscriber’s child or over-age dependent covered under this Contract.
- requires a prescription from your physician;
- is primarily and customarily used only for a medical purpose;
- is appropriate for use in the home;
- is designed for prolonged and repeated use; and
- is not generally useful to a person who is not ill or injured.
DME includes wheelchairs (manual and electric), hospital-type beds, walkers, canes, crutches, kidney machines, ventilators, oxygen, monitors, pressure mattresses, nebulizers, traction equipment, bili blankets, bili lights and respirators.
Endorsements and riders, if any, listed on your Outline of Coverage, are documents that amend your Certificate or Outline of Coverage
The individual (or organization) who has agreed to forward all subscription rates due under your Contract. The Group Benefits Manager is the agent of the subscriber. Your Group Benefits Manager has no authority to act on our behalf and is not our employee or agent.
Health Maintenance Organization. A type of managed care program where you get all of your care from a network of doctors and hospitals. One doctor, your primary care physician (PCP) manages your care and helps you get preventive services and specialty care when you need it.
A patient at a facility who is admitted and incurs a room and board charge. We compute the length of an Inpatient stay by counting either the day of admission or the day of discharge, but not both.
A group of doctors, hospitals or other healthcare professionals that we have contracted with to provide services to our Managed Care members.
Any provider credentialed with Blue Cross and Blue Shield of Vermont or being a member of the Mental Health and Substance Abuse Provider Network, Pharmacy Network, or Vision Service Plan Network. You may get a directory of Network Providers from our customer service department.You may also find a provider on our provider search website. Some providers must join our network for their services to be covered.
A provider that does not meet the definition of a participating provider. For some types of service, we do not provide benefits if you use a non-participating provider.
Deductible plus coinsurance equals out of pocket limit. Most coverage types require members to share costs through deductible and coinsurance for some or all services.
Your Outline of Coverage is the part of your contract that describes payment terms and benefit limitations. It also lists any riders or endorsements that apply to your contract. It is available online, through our secure member portal.
A patient who receives services from a professional or facility while not an inpatient.
Any provider that has made an agreement with Blue Cross and Blue Shield of Vermont; or any provider located out of state that has made an agreement with another Blue Cross and Blue Shield Plan. For some types of service, we do not provide benefits if you do not use a participating provider.
A Point-of-Service plan has two levels of benefits-one that applies when you follow the Plan's managed care guidelines (Preferred Benefits) and one that applies when you choose not to follow these guidelines (Standard Benefits).
Preferred Provider Organization. A healthcare benefit arrangement designed to supply services at a discounted cost by providing incentives for members to use designated healthcare providers who contract with the PPO.
Drugs that are:
- prescribed by a physician for a medical condition,
- FDA-approved, and
- approved by us for reimbursement for the specific medical condition being treated or diagnosed.
Your primary care physician is the doctor you pick when you first join a managed care plan to monitor and manage your care. This doctor is usually a general or family practitioner, an internal medicine specialist or a pediatrician. Your primary care physician should know about all of the care you receive, even when you use specialists or enter facilities.
The required approval that you must get from us before you receive specific services noted in your Contract. In some cases, we require that you get our Prior Approval in writing.
A facility, professional or other provider that is:
- approved by us,
- licensed and/or certified where required, and
- acting within the scope of that license and/or certification.
Some managed care plans require your primary care physician to write you a referral to see another doctor, or you will not enjoy preferred benefits.
Riders and endorsements, if any, listed on your Outline of Coverage, are documents that amend your Certificate or Outline of Coverage.
The individual who enters into a contract with us.