Highmark blue cross blue shield community blue flex ppo

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A copayment may not apply toward deductibles or coinsurance, and may not accumulate toward the out-of-pocket limit. Deductibles, coinsurance, and copayments are examples of member cost sharing.

Covered Service Benefit A service or supply for which health care coverage will be provided by the health plan.

D Deductible A specified dollar amount a member must pay out of their own pocket before the health plan begins to pay for any covered services some services may be exempt from the deductible. The member may be required to pay any applicable deductible at the time of service.

E Exclusive Provider Organization EPO A health care plan which provides benefits when care is received from network providers, and for emergency care when received at either network or out-of-network providers. Explanation of Benefits EOB Statement sent by a health plan that details the charges for the service s received, the plan's allowable charge s for the covered service s , the amount the health plan pays for the service s , and the amount s the member is responsible for paying.

F Fee-for-Service A payment system where the care provider is paid for each service rendered rather than a pre-negotiated amount for each patient. Fee Schedule A complete listing of fees used by health plans to pay doctors or other providers. Flexible Spending Account FSA A health savings account that allows people to contribute a specified amount from their paycheck to help pay for health care services. Contributions are tax-exempt. Formulary A listing of prescription drugs selected by the health plan based on clinical analysis, unique value, and safety.

This listing is subject to periodic review and modification by the health plan or a designated committee of physicians and pharmacists. G Group Health Plan A health plan offered by an employer that provides health coverage to employees and their dependents. Guaranteed Issue Under guaranteed issue, a health insurer must provide coverage to an applicant regardless of prior medical history.

HIPAA helps plan members continue their health coverage and establishes equality between individual and group health coverage. Health Maintenance Organization HMO Health care coverage that requires all members to select a primary care provider PCP who is responsible for supervising, coordinating and providing basic medical services. All non-emergency covered services must be obtained from network providers unless pre-authorized by the health plan. Funds remaining in the account at year-end go back to the employer.

Account contributions are not taxed. Treasury Department. These guidelines require 1. A member must be enrolled in a qualified HDHP to establish and contribute to a health savings account. I Indemnity Traditional fee-for-service health coverage in which covered health care services received from participating providers are paid-in-full after any applied deductibles, copayments or coinsurance costs have been met.

M Maintenance Drugs A prescription drug prescribed for the control of a chronic disease or illness, or to alleviate the pain and discomfort associated with a chronic disease or illness.

Managed Care Health care coverage offered by health plans where there is an organized way for contracting with providers, and processes in place to manage costs, use of services and the quality of the delivery of health care.

Maximum The greatest amount of benefits that the health plan will provide for covered services within a prescribed period of time.

This could be expressed in dollars, number of days or number of services. Medically Underwritten Plans that base acceptance for enrollment on health status, determined by the answers given on a medical questionnaire. N Network Group of physicians, hospitals and other health care providers and suppliers contracted with the health plan to offer health care services at negotiated rates. O Open Enrollment A period each year when a member has the opportunity to change or elect their health care coverage.

Out-Of-Network Provider Physicians, hospitals or other health care providers who do not contract with a health plan. Out-of-Pocket Maximum The maximum dollar amount a member is required to contribute towards the cost of covered services in a benefit period.

This limit protects a member from very high costs by capping the total amount they will have to pay for covered health care services. The out-of-pocket limit always includes coinsurance, and may include other cost-sharing amounts such as copayments or deductibles. Some services may be excluded from the out-of-pocket limit such as prescription drug expenses.

P Participating Provider A health care provider who has been contracted to give medical services or supplies to health plan members for a pre-negotiated fee on indemnity health care plans. Pre-Authorization The process in which a member or provider must contact the health plan prior to a non-emergency hospitalization or other selected services, in order to receive authorization for these services. Pre-existing Condition A condition for which medical advice, care, treatment or diagnosis has been recommended or received from a provider within a designated time period immediately preceding the effective date of coverage.

Pre-existing Waiting Period A specified period of time when the health plan does not cover a member's pre-existing condition s. Not at all.

Competition in health care will help drive lower costs, higher quality and innovations in care. What does it mean for me right now? Members in these products will not have access to all UPMC facilities or doctors on July 1 st Certain services like exception hospitals and some community oncology services will be in-network. Other facilities and services like Hillman and Passavant will still be out-of-network.

However, members will have affordable out-of-network protections for emergency department services at all UPMC facilities. As more details become clear there will be specific outreach to members to clarify how this decision affects them. What about Western Psychiatric Institute and Clinic? Will all of the planned AHN projects in the community continue? Will this change your strategy in investing in AHN and other health systems?

This agreement is focused on Western Pennsylvania and does not impact other regions. Was this article helpful?

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Authorization number not appearing, unable to locate member, questions about clinical criteria screen. Contact Us. Provider Directory. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania.

Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Authorization Requirements. Inpatient admissions e. Inpatient Authorization Guide : Click here for the Predictal step-by-step inpatient authorizations reference guide. Outpatient Authorization Guide : Click here for the Predictal step-by-step outpatient authorizations reference guide.

Questions about authorization workflows. Check status of submitted authorizations. Site Map Legal Information. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern.

Health Plans. Find a Participating Provider Search here to locate a participating PPO provider or find out if your doctor accepts this plan. Questions About Your Benefits? Limitations The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Benefits Office Contact Us. Counseling and Consultation Services for Faculty and Staff.

Coverage for Infertility Services. Stay informed with UHR News.