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80 11/2005
In-Network:
In-network means seeing a provider that has contracted with Blue Cross and Blue
Shield of Georgia and/or Blue Cross Blue Shield Healthcare Plan of Georgia to
participate in the network of physicians and hospitals.
Indemnity:
Indemnity or “traditional” insurance is a plan which reimburses physicians for covered
charges for services performed, or insures for medical expenses incurred.
Inpatient:
A person admitted to a hospital as a bed patient for more than a specific number of
hours.
Length of Stay (LOS):
The number of days that a member stayed in an inpatient facility.
Managed Care:
A prepaid health plan or insurance program in which beneficiaries receive medical
service in a coordinated manner to eliminate payment of unnecessary medical
services. In managed care health plans, the member seeks specialist or hospital care
after prior approval of coverage.
Medical Necessity:
The Plan only pays the cost of covered services it considers medically necessary under
the terms of the member’s contract. The fact that a physician has prescribed,
ordered, recommended or approved a service or supply does not, in itself, make it
medically necessary and a covered service. A service is considered medically
necessary if it is:
• Appropriate and consistent with the diagnosis and the omission of which could
adversely affect or fail to improve the patient’s condition;
• Compatible with the standards of acceptable medical practice in the United States;
• Provided not solely for a member’s convenience or the convenience of the doctor,
healthcare provider, or Hospital;
• Not primarily custodial care; and,
• Provided in a safe and appropriate setting given the nature of the diagnosis and
the severity of the symptoms.