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83 11/2005
Pre-admission Review:
A component of a Utilization Management program which reviews an inpatient
hospital stay prospectively to determine coverage.
Preferred Drug List:
A listing of prescription medications which are approved for coverage by BCBSGa.
The list is subject to periodic review and modification by the health plan.
Preferred Provider Organization (PPO):
A network of hospitals and physicians who agree to participate in a PPO network.
Members of this type of product may incur higher out-of-pocket expenses for
covered services received outside the PPO.
Primary Care Physician (PCP):
A primary care physician is a physician who is a family or general practitioner,
internist or pediatrician. PCPs provide a broad range of routine medical services and
refer patients to specialists, hospitals and other providers as necessary. Each covered
family member who participates in BlueChoice Healthcare Plan or BlueChoice Option,
chooses his or her own PCP from the network’s physicians.
Referral:
If a primary care physician (PCP) determines a member has a condition which requires
the attention of a specialist, the PCP makes a referral to a specialist. Members of
BlueChoice Healthcare Plan must receive a referral prior to seeing most specialists in
order to receive their full benefits. BlueChoice Option members can opt to self-refer
but benefits will be paid at a reduced level.
Service Area:
The geographic area a provider network designates as its boundary limits for
enrolling members.
Specialists:
Providers whose practices are limited to treating a specific disease (e.g., oncologists),
specific parts of the body (e.g., ear, nose and throat), or specific procedures (e.g., oral
surgery).