Admission Review is the review of the Medical Necessity and appropriateness of
non-elective or emergency Hospital admissions. The review takes place within 24 hours
of admission or the next working day.
Refers to the legal Agreement(s) between Blue Cross and Blue Shield of Nebraska and the
healthcare professional, facility or other provider that are included in the policies
and procedures manual. Agreements include but are not limited to the participating
agreement, PPO agreement and the HeartlandCOMP agreement.
Alcoholism or Drug Treatment Center (Treatment Center)
A facility licensed by the Department of Health and Human Services Regulation and
Licensure, whose program is certified by the Division of Alcohol, Drug Abuse, and
Addiction Services (or equivalent state agency), accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or the Commission on the Accreditation
of Rehabilitation Facilities (CARF). Such facility is not licensed as a hospital, but
provides Inpatient or Outpatient care, treatment, services, maintenance, accommodation
or board in a group setting primarily and exclusively for individuals having any type
of dependency or addiction to the use of alcohol or drugs.
Payment is based on the Allowable Charge for Covered Services.
- Inpatient Contracting Hospital or other Institutional Facility: The Allowable Charge
for Covered Services provided by a Contracting institutional facility is the Contracted
Amount for such Services.
- Outpatient Contracting Hospital and other Institutional Provider: The Allowable Charge
for Covered Services provided by an Outpatient Contracting institutional facility is the
lesser of the Contracted Amount or the billed charge.
- Contracting Professional and other Noninstitutional Preferred Providers: The Allowable
Charge for a Covered Service provided by a professional or other noninstitutional
Preferred Provider is the lesser of the Preferred Fee Schedule Amount or the billed
charge. The Allowable Charge for Covered Services in another Service Area is the amount
agreed upon by the On-site Plan and its Participating Providers.
- Contracting Professional and other Noninstitutional Participating Providers: The
Allowable Charge for a Covered Service provided by a non BluePreferred, but
Participating Provider is the lesser of the Maximum Benefit Amount or the billed charge.
The Allowable Charge for Covered Services in another Service Area is the amount agreed
upon by the On-site Plan and its Participating Providers.
The three characters preceding the subscriber identification number on Blue Cross and/or
Blue Shield Plan ID cards. The alpha prefix identifies the member’s Blue Cross and/or
Blue Shield Plan or national account and is required for routing claims.
Ambulatory Surgical Facility
A certified facility which provides surgical treatment to patients not requiring inpatient
hospitalization. Such facility must be licensed as a health clinic as defined by state
statutes, but shall not include the offices of private physicians or dentists, whether
for individual or group practice.
A licensed practitioner of the healing arts who provides Covered Services within the
scope of his or her license or a licensed or certified facility or other health care
provider, payable according to the terms of the member/subscriber contract, Nebraska
law or the direction of the Board of Directors of Blue Cross and Blue Shield of Nebraska.
A certified physician assistant, nurse practitioner, nurse midwife, social worker,
psychiatric registered nurse or other Approved Provider who is performing services
within his or her scope of practice and who is supervised, and billed for, by a
qualified Physician or licensed psychologist, or as otherwise permitted by state
law. Certified master social workers or certified professional counselors performing
Mental Health Services who are not Licensed Mental Health Practitioners are included
in this definition.
Blue Cross and Blue Shield Association’s Web site, which contains useful information
Blue Cross and Blue Shield of Nebraska.
Blue Cross and Blue Shield of Kansas.
A continuous period which starts with the first day a Covered Person is confined in
an acute care Hospital, acute rehabilitation facility, mental health facility,
Alcoholism or Drug Treatment Center or Skilled Nursing Facility. It ends when the
Covered Person has not been in such a facility for 60 days in a row. It includes
the day of admission, but no the day of discharge.(Applicable only to Base Major Medical
Treatment that is goal oriented in assisting the Covered Person to effectively
cope with the loss of a family member. Bereavement Counseling must be performed by
a counselor that is affiliated with a participating Hospice within six months after
the death of a Covered Person who had received Hospice care. The BlueCardSM Program links providers with the independent Blue Cross and Blue Shield Plans across
the country and abroad in a single electronic network for professional, Outpatient
and Inpatient claims processing and reimbursement. The program allows contracting
Blue Cross and Blue Shield providers in every state to submit claims for out-of-state
members to their local Blue Cross and Blue Shield Plan, eliminating the need to track
receivables from multiple Blue Cross and Blue Shield Plans.
Blue Cross and Blue Shield Association
National Association of Independent Blue Cross and Blue Shield Plans; the
organization which works to coordinate the efforts of on-site Blue Cross and Blue
Shield Plans at the national level.
The BlueCardSM Program links providers with the independent Blue Cross
and Blue Shield Plans across the country and abroad in a single electronic network
for professional, Outpatient and Inpatient claims processing and reimbursement. The
program allows contracting Blue Cross and Blue Shield providers in every state to
submit claims for out-of-state members to their local Blue Cross and Blue Shield Plan,
eliminating the need to track receivables from multiple Blue Cross and Blue Shield Plans.
Through the BlueCard Program, providers can submit claims for Blue Cross and Blue
Shield patients visiting from other states directly to BCBSNE. BCBSNE is your contact
for claims payment, problem resolution and adjustments.
BluePreferred Hospital, BluePreferred Phsycian, BluePreferred Provider
Any licensed hospital, practitioner of the healing arts, or qualified provider of
healthcare services, supplies, or home medical equipment who has contracted to provide
Covered Services to Covered Persons as a part of the BluePreferred Provider
Centers for Medicare & Medicaid Services is a branch of the Department of Health
and Human Services which issues rules and regulations for the Medicare program.
An organized effort to identify hospitalized patients whose care may be high-cost,
lengthy, and/or have complicated discharge planning needs; to locate and assess
medically appropriate alternative settings for these patients; and to manage their
health care benefits as cost-effectively as possible. This may include the providing
of alternative or extra-contractual benefits, if the use of such services will reduce
costs, improve the quality of care or will be more medically appropriate than an
alternative covered service.
CPT - Current Procedural
Current Procedural Terminology (CPT) is a book published and updated by the American
Medical Association. This book lists descriptive terms and identifying codes for
reporting medical services. The procedure code that best describes the services
provided is required on claims.
Use of various modalities of treatment to improve cardiac function as well as tissue
perfusion and oxygenation through which selected patients are restored to and maintained
at either a pre-illness level of activity or a new and appropriate level of adjustment.
The organized effort to identify hospitalized patients whose care may be high-cost,
lengthy, and/or have complicated discharge planning needs; to locate and assess
medically appropriate alternative settings for these patients; and to manage their health
care benefits as cost-effectively as possible.
Successful voluntary compliance with certain prerequisite qualifications specified by
regulatory entities. Agencies and programs may be deemed to be in compliance when they are
accredited by the Joint Commission on Accreditation of Health are Organizations (JCAHO),
the Commission on the Accreditation of Rehabilitation Facilities (CARF), American Association
for Ambulatory healthcare (AAAHC), American Association for Accreditation of Ambulatory
Plastic Surgery Facilities (AAAAPSF), Medicare or as otherwise provided in the Contract
provisions or state law.
The amount per service(s) or supply(ies) regularly established by the facility which is billed
to the general public.
Claims submitted by the provider that are accurately completed, submitted in the prescribed
manner and contain all information specified by BCBSNE and which do not require further
information for processing from the provider, Covered Person, or any other party.
A rehabilitative intervention aimed at retraining or facilitating the recovery of mental and
information processing skills including perception, problem-solving, memory storage and
retrieval, language organization and expression.
The percentage of each Allowable Charge which the Covered Person must pay after application of
The review of an ongoing inpatient hospitalization to assure that it remains the most
appropriate setting for the care being rendered. Participating and BluePreferred hospitals and
physicians are encouraged to obtain extensions in benefits beyond precertification through the
Concurrent Review program. If we have been advised of the admission, we will contact the hospital,
treatment center or the physician to determine the treatment plan. On-site concurrent review may
be performed when necessary.
A condition existing at birth which is outside the broad range of normal, such as cleft palate,
birthmarks, webbed fingers or toes. Normal variations in size and shape of the organ, such as
protruding ears, are not considered a Congenital Abnormality.
Physician services by providers with different specialties or subspecialties for a patient in
need of specialized care requested by the attending physician who does not have that expertise
Content of Service
Specific services and/or procedures, supplies and materials that are considered by BCBSNE to be
an integral part of previous or concomitant services or procedures, or all inclusive, to the
extent that separate reimbursement is not recognized. Charges denied as “Content of Service” are
the Participating Provider’s or participating Physician’s liability and may not be billed to the
Refers to legal agreement between Blue Cross and Blue Shield of Nebraska and the group or individual
The payment mutually agreed to by Blue Cross and Blue Shield of Nebraska and the Provider for Covered
Services and Supplies received by a Covered Person.
Coordination of Benefits
Provisions and procedures used by insurers to avoid duplicate payment of benefits by more than one
Any services provided to improve the patient's physical appearance, from which no significant
improvement in physiologic function can be expected, regardless of emotional or psychological factors.
That part of a charge for which benefits would be provided under the terms of the Contract except for
any Coinsurance and Deductible amount.
Any person entitled to benefits for covered services pursuant to a contract underwritten or administered
by Blue Cross and Blue Shield of Nebraska.
Hospital, medical or surgical procedures, treatments, drugs, supplies, home medical equipment, or other
health, mental health or dental care, including any single service or combination of services, for which
benefits are payable, pursuant to a contract underwritten or administered by Blue Cross and Blue Shield
Skilled Nursing Care provided at the home of the Covered Person for up to 24 hours per day. Benefits for
such care are provided in lieu of a Medially Necessary inpatient hospitalization.
The level of care that consists primarily of assisting with the activities of daily living such as
bathing, continence, dressing, transferring and eating. The purpose of such care is to maintain and
support the existing level of care and preserve health from further decline.
Care given to a patient who:
- Is mentally or physically disabled; and
- Needs a protected, monitored or controlled environment or assistance to support the basics of daily
living, in an institution or at home; and
- Is not under active and specific medical, surgical or psychiatric treatment which will reduce the
disability to the extent necessary to allow the patient to function outside such environment or without
such assistance, within a reasonable time, which will not exceed one year in any event.
A custodial care determination many still be made if the care is ordered by a Physician or Services are
being administered by a registered or Licensed practical nurse.
An amount which the Covered Person must pay each calendar year for Covered Services before benefits are
Diagnostic Related Group (DRGs) (Effective October 1 annually)
A patient classification system, developed for the Centers for Medicare and Medicaid Services (CMS),
for classifying hospital or other inpatient facility patients into groups based on criteria of diagnoses,
procedures, age, sex and discharge status. BCBSNE applies the public domain CMS DRG grouper to all
inpatient cases to determine the DRG category of that claim. The DRG grouper application period is inpatient
case discharge dates of 10/1 through 9/30 of the succeeding year. Each year, CMS customarily updates the
DRG grouper to reflect case intensity, new technology, diagnosis and procedure code changes, etc. Payment
rates established by BCBSNE for DRG categories are listed in Attachment II, Exhibit A of the hospital
Agreement. When changes to the DRG grouper result in the establishment of a new DRG category for which no
payment rate has been established by BCBSNE for the applicable fee schedule period, the new DRG will be
reimbursed via the Agreement default payment terms until the next fee schedule update. (Rev 8.13.04)
Discharge Planning is the process of assessing a Covered Person’s need for medically appropriate and timely
discharge. The Hospital and the attending Physician have major responsibility for this function. Blue Cross
and Blue Shield Case Management promotes and assists the Hospital discharge planners.
Eligibility Waiting Period
Applicable to new Members only, the period between the first day of employment and the first date of coverage
under the group or individual applicant Contract.
- The spouse of the Member unless the marriage has been ended by a legal,
effective decree of dissolution, divorce or separation.
- Unmarried children 18 years of age or less who are dependent on the
Member for support and maintenance. A child is dependent so long as he or
she: Child means a grandchild who lives with the Member in a regular child-parent
relationship, a stepchild, adopted child, or a child under a legal
guardianship, but does not include a foster child.
Unmarried children (students) 23 years of age or less for whom the Member
provides support and who are in full-time attendance at an educational
institution which has a curriculum, faculty and student body in attendance.
Coverage will continue during normal school vacation periods.
- lives with the Member, or
- is provided financial support (voluntarily or by order of the court), or
- is provided health coverage by order of the court.
- Reaching age 19, or if a full-time student, age 24, will not end the
covered child's coverage under this contract as long as the child is, and
- incapable of self-sustaining employment, or of returning to school
as a full-time student, by reason of mental or physical handicap; and
- dependent upon the employee / member for support and maintenance.
A medical or behavioral condition, the onset of which is sudden, that manifests
itself by symptoms of sufficient severity, including, but not limited to, severe
pain, that a prudent lay person, possessing an average knowledge of medicine and
health, could reasonably expect the absence of immediate medical attention to
result in one of the following conditions:
- placing the health of the person afflicted with such condition in
serious jeopardy or, in the case of a behavioral condition, placing the
health of such persons or others in serious jeopardy
- serious impairment to such person’s bodily functions
- serious impairment of any bodily organ or part of such person
- serious disfigurement of such person
An individual hired by an Employer or an association who enrolls for health
coverage under this Contract, and is named on an identification card issued
pursuant to this Contract. Enrolled employee is referred to as a Member.
This option provides benefits for covered services provided to the employee
/ member and his or her spouse. Enrolled employee / member is referred to as a
A Group Applicant who signs a master group application for health coverage
on behalf of its Employees.
A provision which expands or modifies a contract
Explanation of Benefits (EOB)
The BCBSNE notice which informs the Covered Person of the benefits allowed on a specific claim.
The EOB reports a breakdown of charges, our payment, and the Covered Person’s liability;
Coinsurance, Deductible, and noncovered amounts.
Explanation of Medicare Benefits (EOMB)
A notice sent to the Medicare beneficiary explaining the Medicare payment.
Membership option providing benefits for Covered Services provided to the Member and his or her
Federal Employee Program (FEP)
The largest nationally underwritten group covering employees of the federal government and their
dependents. FEP members have an identification number that starts with the single alpha prefix “R”.
GABBI (Greater Access to Blue Cross and Blue Shield of Nebraska Information)
The voice response service for healthcare professionals who need to obtain
benefit eligibility information or claim status. Call 1-800-635-0579. Hours are
7 a.m. - midnight, M-F and 7 a.m. - 1 p.m. on Saturday. You will need the
provider number, cardholder’s name and ID number, the patient’s date of birth
and the dates of service.
The Employer or association making application for health coverage under a contract.
HCFA (Health Care Financing Administration)
Health Care Financing Administration is a branch of the Department of Health and Human Services
which issues rules and regulations for the Medicare program.
The form originally developed by the Health Care Financing Association (HCFA) for submitting
Medicare Part B claims. Other Third Party payers also use the form. HCFA 1500 12-90 is the most
recent revision of the form and is the paper claim format requested by Blue Cross and Blue Shield
HCPCS (HCFA Common Procedure Coding System)
Medicare’s National Level II codes – the HCFA Common Procedure Coding System is a 5-digit alpha-numeric
code. This system of coding is an expansion of the CPT coding structure and includes coding for ambulance,
Home Medical Equipment, injectibles, etc., which are not available with CPT coding.
Health Maintenance Organization (HMO)
An entity or organized system of health care that provides, offers or arranges for coverage of designated
health care services to a voluntarily enrolled population in a geographic area for a fixed, prepaid
Home Health Aide Services
Medically Necessary personal care services provided by a licensed or Medicare certified home health agency
to a Covered Person that relate to the treatment of his or her medical condition. Such services must be
ordered by a Physician, and performed under the supervision of a registered nurse. Such services include,
but are not limited to bathing, feeding, and performing household cleaning duties directly related to the
Home Infusion Therapy
Medically Necessary Covered Services and supplies required for administration of a Home Infusion Therapy
regimen when ordered by a Physician.
Home (Durable) Medical Equipment (HME)
Equipment and supplies medically necessary to treat an Illness or Injury, to improve the functioning of
a malformed body member, or to prevent further deterioration of the patient's medical condition.
Such equipment and supplies must be designed and used primarily to treat conditions which are medical in
nature, and able to withstand repeated use. Home medical equipment includes such items as prosthetic
devices, orthopedic braces, crutches and wheelchairs. It does not include sporting or athletic equipment
or items purchased for the convenience of the family.
An individual will be considered to be essentially homebound if he or she has a condition due to an
illness or injury which considerably restricts the ability to leave his or her residence without the aid
of supportive devices, the use of special transportation or the assistance of another person. The patient
who does leave the residence may still be considered homebound if the absences from the place of residence
are infrequent or for periods of relatively short duration and attributable to the need to receive medical
treatment that cannot be provided in the home.
Hospice care is a program of care for person diagnosed as terminally ill, and their families. Hospice
- Home Health Aide Services;
- Hospice Nursing Services provided in the home;
- Respite Care;
- Medical Social Services;
- Crisis Care; and
- Bereavement Counseling.
A Hospital is an institution or facility licensed by the state of Nebraska or the state in which it is
located, which provides medical and surgical diagnostic and treatment services with 24-hour per day nursing
services, to two or more unrelated persons with an Illness, Injury or Pregnancy, under the supervision of
a staff of Physicians licensed to practice medicine and surgery.
A Hospital is an institution or facility licensed by the state of Nebraska or the state in which it is located,
which provides medical and surgical diagnostic and treatment services with 24-hour per day nursing services,
to two or more unrelated persons with an Illness, Injury or Pregnancy, under the supervision of a staff of
Physicians licensed to practice medicine and surgery.
A condition which deviates from or disrupts normal bodily functions or body
tissues in an abnormal way, and is manifested by a characteristic set of signs
Physical harm or damage inflicted to the body from an external force.
Base reimbursement amount for a DRG. When Covered Charges are less than Inlier
Rate, the reimbursement is the Inlier Rate.
A patient admitted to a Hospital or other facility for bed occupancy to receive
services consisting of active medical and nursing care to treat conditions
requiring continuous nursing intervention of such an intensity that it cannot be
safely or effectively provided in any other setting.
The period from entry (admission) into an acute care Hospital, acute
rehabilitation, mental health facility, skilled nursing facility, or alcoholism
or drug treatment center until discharge from that facility.
International Classification of Diseases. 9th Revision, Clinical Modification (ICD-9-CM)
ICD-9-CM is a comprehensive list of diagnosis codes and narrative. ICD-9-CM is
based on the International Classification of Diseases, 9th Revision; Clinical
Modification codes and instructions; as well as Medicare regulations and manuals
issued by the Centers for Medicare & Medicaid Services (CMS) and by the Health
Care Financing Administration (HCFA). Diagnosis is required on Blue Cross and
Blue Shield of Nebraska claims.
A technology, a drug, biological product, device, diagnostic, treatment or procedure is investigative
if it has not been scientifically validated pursuant to all of the factors set forth below.
- The technology, drugs, biologicals, products, devices and diagnostics must have final approval
from the appropriate government regulatory bodies. A drug or biological product must have final
approval from the Food and Drug Administration (FDA). A device must have final approval from the
FDA for those specific indications and methods of use that are being evaluated.
- The scientific evidence must permit conclusions concerning the effect of the technology on
health outcomes. The evidence should consist of well-designed and well-conducted investigations
published in peer-reviewed journals. The quality of the body of studies and the consistency of
the results are considered in evaluating the evidence. The evidence should demonstrate that the
technology can measure or alter the physiological changes related to a disease, injury, illness
or condition. In addition, there should be evidence based on established medical facts that such
measurement or alteration affects the health outcomes. Opinions and evaluations by national medical
associations, consensus panels or other technology evaluation bodies are evaluated according to the
scientific quality of the supporting evidence and rationale. Our evidence includes, but is not
limited to: Blue Cross and Blue Shield Association Technology Evaluation Center technology
evaluations; Hayes Directory of New Medical Technologies' Status; Health Care Financing
Administration (HCFA); Centers for Medicare & Medicaid Services (CMS) Technology Assessments;
and United States Food and Drug Administration (FDA) approvals.
- The technology must improve the net health outcome.
- The technology must improve the net health outcome as much as or more than established
- The improvement must be attainable outside the Investigative settings Blue Cross and Blue
Shield of Nebraska will determine whether a technology is investigative.
Permission to engage in a health profession which would otherwise be unlawful in the state
where services are performed, and which is granted to individuals who meet prerequisite qualifications.
Licensure protects a given scope of practice and the title.
A system of healthcare delivery that influences utilization and cost of services and measures performance.
The goal is a system that delivers value by giving access to quality, cost-effective healthcare.
Maximum Coinsurance Liability Limit
The coinsurance limit is the total of the Covered Person's Coinsurance payment amounts under all parts
of the Contract, except those specified, during each calendar year.
Grants to states for Medical Assistance Programs, Title XIX of the Social Security Act, as amended.
Medically Necessary or Medical Necessity
Medically Necessary or Medical Necessity: Healthcare Services ordered by a Treating Physician exercising
prudent clinical judgment, provided to a Covered Person for the purposes of prevention, evaluation,
diagnosis or treatment of that Covered Person's Illness, Injury or Pregnancy, that are:
- consistent with the prevailing professionally recognized standards of medical practice; and known
to be effective in improving health care outcomes for the condition for which it is recommended or
prescribed. Effectiveness will be determined by validation based upon scientific evidence, professional
standards and consideration of expert opinion, and
- clinically appropriate in terms of type, frequency, extent, site and duration for the prevention,
diagnosis or treatment of the Covered Person's Illness, Injury or Pregnancy. The most appropriate
setting and the most appropriate level of Service is that setting and that level of Service, which is
the most cost effective considering the potential benefits and harms to the patient. When this test
is applied to the care of an Inpatient, the Covered Person's medical symptoms and conditions must
require that treatment cannot be safely provided in a less intensive medical setting; and
- not more costly than alternative interventions, including no intervention, and are at least as
likely to produce equivalent therapeutic or diagnostic results as to the prevention, diagnosis or
treatment of the patient's Illness, Injury or Pregnancy, without adversely affecting the Covered
Person's medical condition; and
- not provided primarily for the convenience of the following:
- the Covered Person;
- the Physician;
- the Covered Person's family;
- any other person or health care provider; and
- not considered unnecessarily repetitive when performed in combination with other prevention,
evaluation, diagnoses or treatment procedures. Blue Cross and Blue Shield of Nebraska will determine
whether services are Medically Necessary. Services will not automatically be considered Medically
Necessary because they have been ordered or provided by a Treating Physician.
BCBSNE Utilization Review will determine whether services provided are Medically
Necessary. Services will not automatically be considered Medically Necessary
because they have been ordered or provided by a Physician.
Health Insurance for the Aged and Disabled, Title XVIII of the Social Security Act, as amended.
A person named on an identification card issued pursuant to a Member, group or individual Contract.
Enrolled employee is referred to as a Member.
Mental Health Services or Practice
A qualified physician, licensed psychologist, licensed special psychologist, and licensed mental
health practitioners who are payable providers under the covered person’s contract. A mental
health practitioner may also be called a licensed professional counselor or a licensed social
worker who is a duly certified/licensed professional acting within the scope of his or her practice
according to state law. It also includes, for purposes of the contract, auxiliary providers; who
are working under supervision and billed for by a professional as permitted by state law. All
mental health services must be provided under appropriate supervision and consultation requirements
as set forth by state law.
Licensed clinical psychologist
Psychologist shall mean a person licensed to engage in the practice of psychology in this
or another jurisdiction. The terms certified, registered, chartered, or any other term chosen
by a jurisdiction to authorize the autonomous practice of psychology shall be considered
Licensed special psychologist
A person who has a doctoral degree in psychology from an institution of higher education
accredited by the American Psychological Association but who is not certified in psychology.
Such person shall be issued a special license to practice psychology that continues existing
requirements for supervision by a licensed psychologist or qualified physician for any practice
that involves major mental and emotional disorders. This psychologist may provide mental health
services without supervision.
Licensed mental health practitioner
A person Licensed to provide treatment, assessment, psychotherapy, counseling, or equivalent
activities to individuals, families or groups for behavioral, cognitive, social, mental, or
emotional disorders, including interpersonal or personal situations. Mental health practice
shall include the initial assessment of organic mental or emotional disorders (as defined by
state law), for the purpose of referral or consultation to a qualified physician or a licensed
Mental Health Practice shall not include the practice of psychology or medicine, prescribing
drugs or electroconvulsive therapy, treating physical disease, Injury, or deformity, diagnosing
major mental illness or disorder except in consultation with a qualified physician or a licensed
psychologist measuring personality or intelligence for the purpose of diagnosis or treatment
planning, using psychotherapy with individuals suspected of having major mental or emotional
disorders except in consultation with a qualified physician or licensed psychologist, or using
psychotherapy to treat the concomitants of organic illness except in consultation with a qualified
physician or licensed psychologist.
A pathological state of mind producing clinically significant psychological or physiological symptoms
(distress) together with impairment in one or more major areas of functioning (disability) wherein
improvement can reasonably be anticipated with therapy. Also referred to as MIDA (Mental Illness, Drug
Abuse and Alcoholism.
A means by which the reporting Physician can indicate that a service or procedure performed has been
altered by some specific circumstance but not changed in its definition or code. The Modifier is added
to the CPT code of the service that has been altered.
A group which has employees in more than one Plan area. Claims are processed by the on-site Plan
servicing the area where care was received.
The period of treatment when the physician is evaluating the patient’s medical condition to determine
whether the patient can be released from the outpatient department or admitted to the facility as an
inpatient; or the period of treatment following an outpatient procedure when the physician is evaluating
the patient’s medical condition to determine whether the patient can be released from the outpatient
department. The maximum reimbursement amount for an observation period is up to one day’s accommodation
charge. This period of observation time must not exceed 24 hours or the patient will be considered an
Optical Character Recognition (OCR)
The ability of a piece of equipment to read a typed or written document and transfer the information
into computer language.
The defined point at which Covered Charges exceed the expected charges for a DRG category, and additional
reimbursement is added to the base reimbursement (Inlier Rate).
When Covered Charges are less than the Outlier Threshold, the reimbursement is the Inlier Rate. When
Covered Charges exceed the Outlier Threshold, the reimbursement is the total of the Inlier Rate plus a
percentage of the amount above the defined Outlier Threshold.
A person treated in the outpatient department or emergency room of a Hospital, or in a free-standing
Ambulatory Surgical Facility, or a Physician's office – a person not admitted for Inpatient treatment.
An organized set of resources and services for a substance abusive or mentally ill population, administered
by a certified provider, which is directed toward the accomplishment of a designed set of objectives. Day
treatment, partial care and outpatient programs which provide primary treatment for mental illness or
substance abuse must be provided in a facility which is licensed by the Department of Health and Human
Services Regulation and Licensure and whose program is certified by the Division of Alcoholism, Drug Abuse
and Addiction Services (or equivalent state agency) or accredited by the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) or the Commission on the Accreditation of Rehabilitation Facilities
This definition does not include programs of co-dependency, family intervention, employee assistance,
probation, prevention, educational or self-help programs, or programs which treat obesity, gambling, or
nicotine addiction. It also does not include residential or day rehabilitation services for mental illness,
or residential, halfway house or methadone maintenance programs for substance abuse. Benefits will not be
provided for programs ordered by the court which are not medically necessary as determined by Blue Cross
and Blue Shield of Nebraska.
Under Blue Cross and Blue Shield of Nebraska’s traditional program, any licensed hospital, practitioner of
the healing arts, or qualified provider of healthcare services, supplies or home medical equipment who has
contracted to provide Covered Services to Covered Persons.
Inpatient Hospital, acute care, acute rehabilitation facility, mental health facility, Alcoholism or Drug
Treatment Center or skilled nursing facility days. The day of admission shall be counted, but the day of
discharge shall not be counted.
(Exception: When the patient is discharged on the same day as admitted or is transferred to another acute
care facility on the same day as admitted.)
The restoration of a person who was totally disabled as the result of an Injury or an acute physical
impairment to a level of function which allows that person to live as independently as possible. A person
is totally disabled when such person has physical disabilities and needs active assistance to perform the
normal activities of daily living, such as eating, dressing, personal hygiene, ambulation and changing body
Any person holding a license who is duly authorized to practice medicine, practice surgery and prescribe drugs.
An individual organization participating in the Blue Cross and Blue Shield Association.
Point of Service
A plan which incorporates Managed Care through a primary care Physician who coordinates care within a
network of providers with the option to self-refer out of the network to a provider of choice at the time of
treatment. Reimbursement levels vary based on the option selected. The Point of Service plans are administered
by HMO Nebraska, Inc., with out-of-network services available from Participating Providers.
Preadmission Review is the review and assessment of the medical necessity and appropriateness of nonemergency
hospital admissions before hospitalization occurs. The appropriateness of the site and level of care is assessed
along with the timing and duration of the proposed hospitalization.
Preauthorization of benefits is prior written approval of benefits for certain services such as organ transplants,
subsequent purchases of Home Medical Equipment, Physical Rehabilitation and other services specified under the
contract. This preauthorization is based on the terms of the benefits Contract and on the information submitted
to Blue Cross and Blue Shield of Nebraska. Preauthorization may be effective for a limited period of time. The
Covered Person should encourage the Provider to request preauthorization in order to determine whether benefits
for certain services are payable.
Preferred Provider Organization
A panel of Hospitals, Physicians and other health care Providers who belong to a network of Preferred Providers,
which agrees to more effectively manage healthcare costs.
A condition, whether physical or mental, regardless of the cause of the condition, for which medical advice,
diagnosis, care, or treatment was recommended or received within the six-month period ending on the first day
of coverage, or if there is an Eligibility Waiting Period, the first day of such Waiting Period. A Pre-Existing
Condition does not include a Pregnancy when coverage is subject to the Health Insurance Portability and
Accountability Act of 1996.
Includes obstetrics, abortions, threatened abortions, miscarriages, premature deliveries, ectopic pregnancies,
or other conditions or complications caused by Pregnancy. A complication caused by Pregnancy is a condition
that occurs prior to the end of the Pregnancy, distinct from the Pregnancy, but caused or adversely affected
by it. Postpartum depression and similar diagnoses are not considered complications of Pregnancy as that
terminology is used in the Contract.
The condition which is determined to be the primary reason for treatment.
The procedure performed for definitive treatment, rather than for diagnostic or exploratory purposes, or to
resolve a complication. More than one procedure may meet this definition and may be listed on the claim.
The five-position number assigned to you when submitting claims to Blue Cross and Blue Shield of Nebraska (BCBSNE).
RBRVS (Resource Based Relative Value Scale)
RBRVS system assigns a value of each medical procedure or service based on the resources the Physician or
Provider used including physical or procedural resources, educational, mental or cognitive, and financial
RBRVS was based on a study developed at Harvard University. An advisory committee provided by the American
Medical Association made contributions through the length of the study.
Remittance Advice (RA)
The BCBSNE claim payment report for participating Hospitals, Physicians and other providers of health care
services. The RA is a record of how payment was made: total Charges, Covered Person’s liability, Provider
liability, and BCBSNE payment.
Short-term Inpatient care which is necessary for the Covered Person in order to give temporary relief to
the person who regularly assists with the care at home. Respite Care may be provided in the Hospice program’s
designated Inpatient unit that is affiliated with the Hospice that is providing services to the Covered
Person, in an acute care setting in a Hospital or in a skilled nursing facility.
Rx Nebraska Information Network
This audio response system verifies a patient’s prescription drug card eligibility copay amounts and effective
Membership option providing benefits for Covered Services provided to the Member only.
Single Parent Membership
Membership option providing benefits for Covered Services provided to the Member and his or her eligible dependent
children, but not to a spouse.
Skilled Nursing Care or Service
Medically Necessary Inpatient Skilled Nursing services for the treatment of an Illness or Injury that must be
ordered by a Physician, and performed under the supervision of a Registered Nurse (R.N.) or a Licensed Practical
Nurse (L.P.N.). The classification of a particular service as skilled is based on the technical or professional
health training required to effectively perform the service. Services by other licensed professional providers
within their scope of practice, and ordered by a Physician, are considered to be included in Skilled Nursing Care.
A nursing service is not considered skilled merely because it is performed by a R.N. or a L.P.N. The service
cannot be regarded as Skilled Nursing when it can be safely and effectively performed by the average nonmedical
person (or self-administered) without the direct supervision of a Licensed nurse.
Subrogation is our right to recover benefits paid for Covered Services as the result of an Injury or Illness which
was caused by a third party. We also assert a contractual right of recovery to collect proceeds recovered from a
third party. Subrogation and the contractual right of recovery are prior liens against any proceeds recovered by
the Covered Person.
Claims will be paid according to the Covered Person's Contract, then BCBSNE will seek reimbursement from the
other party. The recovery amount will not exceed the amount we paid in benefits.
For purposes of the Contract, this term is limited to alcoholism and drug abuse. (See Mental Illness).
The ready availability of the Physician for consultation and direction of the activities of another provider
who is providing healthcare services within his or her defined scope of practice.
Tax Identification Number (TIN)
The TIN is the number you use to file income tax with the IRS.
A company, organization, insurer or government agency which makes payment for health care services received
by a patient. Blue Shield Plans, commercial insurance companies, Medicare, Medicaid, HMOs and PPOs. The patient
and the provider of service are the first two parties to the delivery of health care services; the insurer
becomes the third party.
Transfer Per Diem
When a patient is transferred between two or more Hospitals, and a Transfer Per Diem has been set for the
applicable DRG, the transferring Hospital will be reimbursed an all-inclusive Contracted Amount for each Medically
Necessary inpatient day.
The Uniform Bill UB-92 is intended to be used by the major Third Party Payers, most Hospitals and nursing homes.
The data elements and design of the form are determined by the National Uniform Billing Committee. The MUBC has
developed uniform definitions and procedures for completing the form. The procedural guidelines are designed to
provide actual completion instructions for each payer.
The evaluation by Blue Cross and Blue Shield of Nebraska or its designees, of the use of services, including
medical, diagnostic or surgical procedures or treatments, the utilization of medical supplies, drugs, or home
medical equipment or treatment of mental illness, alcoholism and drug abuse or other health or dental care,
compared with established criteria in order to determine benefits.
Components of the Utilization Review program include Preadmission Review, Admission Review, Concurrent Review,
Discharge Planning and Case Management.
Benefits may be excluded for services, procedures, supplies, drugs or home medical equipment if they are found
to be not Medically Necessary according to Blue Cross and Blue Shield of Nebraska criteria.
The period of time during which no benefit payment will be made for services provided to a covered person for
a Pre-Existing Condition.
Physical therapy or similar services provided primarily for strengthening an individual for purposes of his or
The Nebraska Workers’ Compensation laws are designed to provide certain benefits to employees who
- sustain injury or contract occupational disease
- arising out of an in the course of their employment and
- are not willfully negligent at the time of their injury.
The Nebraska Worker’s Compensation Act applied to most employers in Nebraska; however, some exceptions include
employers of farm or ranch laborers and domestic workers, independent contracts and nonincorporated business
owners. The NWCA applies.