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77 11/2005
Coordination of Benefits (COB):
A provision in a contract that applies when a person is covered under more than one
group medical program. It requires that payment of benefits will be coordinated by all
programs to eliminate over-payment by insurance or duplication of benefits.
Copayment or Copay:
The payment made by a member of an HMO or point-of-service or the user of a PPO
at the time a selected service is rendered. Examples include copayment for each
physician’s office visit and for each hospital admission.
Covered Person:
An individual who meets eligibility requirements and for whom premium payments
are paid for specified benefits of the contractual agreement. Covered Person is also
referred to as member, covered individual, enrollee or insured.
Credentialing:
The process of reviewing a provider’s credentials, i.e., training, experience, or
demonstrated ability, for the purpose of determining if criteria for inclusion in a
network are met. Blue Cross and Blue Shield of Georgia and Blue Cross Blue Shield
Healthcare Plan of Georgia screen all physicians in their networks. Each physician
must meet specific educational and medical practice standards in order to become
part of the network.
Deductible:
The amount of covered expenses that must be incurred by each member before
benefits become payable by the insurer. For example, if a plan has a $100
deductible, the deductible is met once the first $100 of the covered medical expenses
for that year have been paid. After that, the plan begins to pay a specified percentage
toward the cost of covered health care services.
Dependent:
A covered person’s spouse (not legally separated from the insured) and unmarried
child(ren) who meet eligibility requirements.
Discharge Planning:
Component of Utilization Management program which evaluates a member’s coverage
under the terms of the member’s contract for health care services after discharge
from an inpatient setting.