Health Insurance Glossary

Paid By CareFirst
The amount CareFirst paid to health care provider(s) or the subscriber for services covered by the Explanation of Benefits.
Partial Day Treatment
A program offered by licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.
Participating Provider
Individual physicians, hospitals and professional health care providers who have a contract with CareFirst BlueCross BlueShield and/ or CareFirst BlueChoice, Inc. to provide services to its members at a discounted rate and to be paid directly for covered services. See Non-Participating Provider.
Patient’s Responsibility
The amount that the provider can collect from the patient for the services indicated. The Deductible and Co-pay/Co-insurance amounts and some Non-Allowed Amounts and Benefit Reduction Amounts are included. Your responsibility amount depends on the type of coverage you have, what other type of insurance coverage is involved, and if the provider participates in the CareFirst plan. If the payment was made to a non-participating provider, the subscriber or other designated payee, your responsibility will reflect the charge minus CareFirst payment and any other insurance payment, except Medicare non-assigned payments.
See Primary Care Physician (PCP).
Physical Therapy
Treatment by a licensed therapist involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.
Plan Allowance (Allowed Amount or Allowable Charge)
The maximum dollar amount a contract allows for services covered, regardless of the provider's actual charge. A provider who participates in the network cannot charge the member more than this amount for any covered service.
Plan Benefit Maximum
See Lifetime Maximum.
Point-of-Service (POS) plans
These plans include in-network (HMO) and out-of-network (PPO or traditional major medical) options that enable members to select which network and level of benefits they want to utilize at the time services are required.
The employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract.
Approval necessary for designated procedures or hospital admissions. When care is received in-network, the primary care physician or specialist is usually responsible for obtaining pre-authorization. For out-of-network services, the member is responsible for obtaining pre-authorization.
See Pre-Authorization.
Pre-Existing Condition
An illness or condition that you or another member had prior to applying for health insurance. In some cases, these conditions may be subject to a waiting period for benefits or excluded from coverage.
Preferred Drug List
Also known as a formulary, this is a list of certain brand name and covered generic prescription drugs. The preferred drug list was developed and is maintained by the CareFirst BlueCross BlueShield Pharmacy and Therapeutics Committee, which is made up of a group of physicians and pharmacists that practice in the CareFirst BlueCross BlueShield region. CareFirst BlueCross BlueShield may change this list from time to time to provide the most cost-effective and complete prescription drug options to members. See Formulary.
Preferred Provider Organization (PPO)
An agreement between a medical provider and a health care carrier for the delivery of services to a specific member population using discounted fees for cost savings. This relates to only a fee arrangement, and does not imply that any provider is more or less qualified than another.
Periodic amounts paid by or on behalf of members for ongoing health care coverage. It does not include any deductibles or copayments the plan may require.
A written order or refill notice issued by a licensed medical professional for drugs or devices (e.g., syringes, needles for diabetics) that are only available through a pharmacy.
Preventive Care
Care rendered by a physician to promote health and prevent future health problems for a member who does not exhibit any symptoms. Examples are routine physical examinations and immunizations.
Primary Care Physician (PCP)
A physician selected by the member, who is part of the plan network, who provides routine care and coordinates other specialized care. The PCP should be selected from the network that corresponds to the plan in which you are a member. The physician you choose as your PCP may be a family or general practitioner, internist or pediatrician.
Prior Authorization
See Pre-Authorization.
Prior Authorization List
This is a list of brand name and generic prescription drugs developed and maintained by CareFirst BlueCross BlueShield and used by providers and pharmacists when writing and filling prescriptions. Prior Authorization is used to insure the appropriate use of medications that have specific indications, safety concerns, or have a high potential for overuse.
Prosthetic Devices
A device which replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Provider Network
The set of providers contracted with a health plan to provide services to the members. In the case of a fee-for-service or non-network health plan, the provider network is generally all licensed providers of covered services.