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76 11/2005
Board Certified (Boarded, Diplomat):
Describes a physician who has passed a written and oral examination given by a
medical specialty board and who has been certified as a specialist in that area.
Case Management:
A method of coordinating and facilitating services and benefits members receive to
ensure they seek and receive appropriate and necessary care to minimize duplication
of services, tests and costs and to maximize benefits available under their
Membership Agreement.
Certificate Booklet:
A detailed document that serves both as an explanation of the benefit plan and as the
certificate of insurance. See certificate of coverage.
Certificate of Coverage:
A description of the benefits included in an insurance plan. The certificate of
coverage is required by state insurance laws and represents the coverage provided
under the policy issued to the contract holder. The certificate is provided to
subscribers via the Certificate Booklet (also referred to as Membership Agreement).
Claim:
A demand to the insurer or employee benefit plan by the insured, plan participant or
beneficiary for the payment of benefits under a policy.
Coinsurance:
A policy provision frequently found in major medical insurance policies under which
the insured individual and the insurer share hospital and medical expenses according
to a specified ratio.
Concurrent Review:
A component of Utilization Management program which evaluates a member’s
coverage for hospital services under the terms of the contract.
Contract:
A binding written agreement between the insurer and policyholder to evidence the
terms and conditions of the policy. The contract between BCBSGa or Blue Cross Blue
Shield Healthcare Plan of Georgia and an insured includes the certificate booklet (also
known as the Membership Agreement).