Terminology

2. Representative who “Stands in the shoes of the Member”
3. A Blue Cross and Blue Shield Plan serving a specific geographic area
5. Percentage of the cost of the service the insured pays.
9. A plan's description of benefits, limitations, exclusions, and definitions under the FEHB Program
12. In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review.
15. The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full.
16. A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.
17. Abbreviation for a plan available to employees, former spouses or dependents who lose eligibility under the Federal Employees Health Benefits (FEHB) coverage due to a qualifying event.
18. A spouse or child of a deceased federal employee or annuitant who meets the criteria of OPM to continue coverage.
19. A doctor, hospital, health care practitioner, pharmacy, or health care facility
20. A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

1. Written assurance that benefits will be provided.
4. A fixed amount a group member must pay before the insurer will make any benefit payments.
6. A building or place that provides a particular service or is used for a particular industry
7. A patient who receives treatment at a hospital, either at a single attendance or a series of attendances, but is not admitted to a bed in the hospital.
8. Representative who's authority is limited, current involvement/best interest/or member directed. Authority must be evaluated each contact
10. A federal law that outlines the requirements that employer, sponsored group insurance plans, insurance companies, and managed care organizations must satisfy in order to provide health insurance coverage in.
11. This is the annual enrollment period when federal employees and annuitants can change options or change their type of coverage among the various health benefits plans.
13. Representative who's authority is limited and can only receive PHI. Limited to 1 year.
14. The group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.