Amount Allowed
The amount that Blue Shield determines is appropriate payment for a service. Physicians who have contracted with Blue Shield must accept this amount as payment in full. If a member chooses to go outside of our networks, he or she may be responsible for a much larger payment. For more details about your plan's amount allowed, please refer to your Evidence of Coverage/Certificate of Insurance.
Amount Billed
The amount your provider billed for the services you received.
Amount Saved by Using a Network Provider
The amount you saved by using a Blue Shield network provider.
Amount We Paid
The amount we paid to your provider or you.
Claim Number
Blue Shield assigns a 14-digit number to each claim record. This number allows Blue Shield to uniquely identify the claim. When a claim is adjusted, the claim receives a new number.
Copay
See Copayment/Coinsurance.
Copayment/Coinsurance
The predetermined amount (copayment) for which you are responsible or a percentage of the cost (coinsurance) for which you are responsible, based on your plan benefits. You are responsible for this amount. For more details about your plan's copayment/coinsurance, please refer to your Evidence of Coverage/Certificate of Insurance.
Copayment Maximum
This is the most money you will be required to pay in a year for applicable services. Your copayment responsibility for most services applies toward this copayment maximum.
Copayment Maximum Benefits
These are benefits covered by your health plan that apply toward your copayment maximum.
Date(s) of Service
The day or dates the patient received services from the provider.
Deductible
The dollar amount that you must pay for covered services each year before we start paying benefits under your plan. You are responsible for this amount. You may have two kinds of deductibles: medical and pharmacy. Your medical deductible applies to covered services such as physician office visits. Your pharmacy deductible applies to outpatient drugs obtained from a participating provider. For more details about your plan's deductible, please refer to your Evidence of Coverage/Certificate of Insurance.
Evidence of Coverage or Certificate of Insurance
The official Blue Shield documents that describe member benefits, copayments, exclusions and limitations.
First Dollar Amount
The personal fund that a member can spend for certain services. Once you have spent the first dollar amount, you are responsible for 100% of the medical costs on applicable services until you meet your copayment maximum.
Lifetime Maximum
This is the maximum amount of money Blue Shield will pay for covered services throughout your entire life while you are covered under your health plan. Check your Evidence of Coverage/Certificate of Insurance to determine if a lifetime maximum applies to your specific plan or policy.
Medical Group
An organization of medical professionals -- generally located in the same facility -- who provide a range of health care services.
Non Covered
The portion of the Amount Billed not covered by your plan. You are responsible for this amount.
Non-Preferred Provider
A doctor, hospital or other medical professional that is not under contract with Blue Shield and not a designated member in the Blue Shield network. If members choose a provider that is not in our network, they may be responsible for additional payments above and beyond the Blue Shield allowed amount.
Patient Responsibility
The amount you are responsible to pay the provider. It consists of Deductible, Copayment/Coinsurance and Non Covered amounts.
Primary Care Physician
For our Blue Shield HMO and POS members, their primary care physician is the doctor responsible for their medical care. As soon as you become a member, you must choose a primary care physician. This physician is usually your first contact for health care, treats most of your health problems and coordinates your health plan benefits. If necessary, he or she will also refer you to a specialist.
Preferred Provider
A preferred provider is a doctor, hospital or other medical professional in the Blue Shield network. These providers are under contract with us to provide health services to our members. As providers within our network, they have agreed to accept the allowed amount as payment in full -- which usually results in cost savings for our member.
Prescription Mail Service: Brand Mail & Generic Mail
If you are taking a medication for a chronic condition such as diabetes on an ongoing basis and your dosage is stable, you may want to use the Express Scripts mail-service pharmacy to have a 60- or 90-day supply sent to you. In addition, members may receive reduced copayment amounts through this service. If you see a copay range, your pharmacist will calculate your copayment as follows: Your cost =copay amount + [(cost of the drug - copay) times a percentage of the difference]. For example, if the total cost of the drug is $300 with a copay of $45, calculate 10% like this: ($300-$45)=$255x10%=$25.50. Therefore, your total copay is $45+$25.50=$70.50.
Prior Authorization
Some services require prior authorization before treatment, in addition to your doctor's referral. A referral and this prior authorization are two different things. For example, some of these services include surgical procedures, hospital stays, radiological treatments, etc. Before receiving treatment, call the Member Services number listed on your Blue Shield ID card to obtain a "prior authorization."
Rx-Brand
A drug produced and sold under the original manufacturer's brand name. If you select a brand-name drug that is available in generic form, you will probably pay the difference between Blue Shield's cost for the brand-name drug and the generic drug (in addition to any copays you may have). If you see a copay range, your pharmacist will calculate your copayment as follows: Your cost =copay amount + [(cost of the drug - copay) times a percentage of the difference]. For example, if the total cost of the drug is $300 with a copay of $45, calculate 10% like this: ($300-$45)=$255x10%=$25.50. Therefore, your total copay is $45+$25.50=$70.50. Generic drugs are almost always less expensive than brand-name drugs.
Rx-Generic
These are drugs that are equivalent to, and almost always less expensive, than brand-name drugs. If you see a copay range, your pharmacist will calculate your copayment as follows: Your cost =copay amount + [(cost of the drug - copay) times a percentage of the difference]. For example, if the total cost of the drug is $300 with a copay of $45, calculate 10% like this: ($300-$45)=$255x10%=$25.50. Therefore, your total copay is $45+$25.50=$70.50.
Rx-Non-Formulary
This is medication that has a lower cost alternative listed in our drug formulary. Some plans do not provide benefits for non-formulary drugs (those plans that do may have a higher copay). If you see a copay range, your pharmacist will calculate your copayment as follows: Your cost =copay amount + [(cost of the drug - copay) times a percentage of the difference]. For example, if the total cost of the drug is $300 with a copay of $45, calculate 10% like this: ($300-$45)=$255x10%=$25.50. Therefore, your total copay is $45+$25.50=$70.50.
Self-Referred Office Visit
For our HMO and POS members, this benefit allows you to go directly to a specialist in your Personal Physician's medical group or IPA (Individual Physician Association) without a referral.