Glossary

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Accepting New Patients — 

A doctor or other health care professional who is available to patients who have not been previously seen at the practice. This information is collected before a doctor or other health care professional joins our network(s), and it is verified at least every 36 months upon re-credentialing or as new information is received. This information may change at any time. We recommend contacting the doctor’s or other health care professional’s office to confirm this is correct.

Accountable Care Organization (ACO) — 

A group of health care providers held jointly accountable for achieving measure quality results and avoiding unnecessary medical costs.

Actual Charge and Allowable Charge — 

Members may have seen the sentence, “The actual charge may be different from the allowable charge.” This means that Horizon BCBSNJ may only cover a portion of what a health care provider charges. For example, a doctor bills $40 for an office visit. This is the actual charge. But Horizon BCBSNJ may only allow $35 for an office visit. This is the allowable charge. The allowable charge for a service or supply is determined by Horizon BCBSNJ or the negotiated fee schedule.

Acupuncture — 

A practice in which specific body areas are pierced with fine needles for therapeutic purposes, to relieve pain or to produce surgical anesthesia.

Administrative Services Only (ASO) Group — 

A group that contracts with Horizon BCBSNJ to provide specified administrative and claims payment services, as described in the group's contract. The group assumes the risk for the cost of the services the covered members of the group receive.

Adolescent Medicine — 

A specialty focusing on the diagnosis and treatment of diseases occurring during the period beginning with puberty until the cessation of bodily growth.

Allergy and Immunology — 

A specialty focusing on the diagnosis of disorders caused by hypersensitivity to various substances.

Ambulance Provider — 

Provider of emergency transportation for patients to a medical facility in cases of accident, trauma or sudden, severe illness. For non-emergency transportation, please see Medical Transportation Provider.

Ambulatory Care — 

Medical care provided on an outpatient basis to persons who are able to walk about (i.e., not bed-ridden or hospitalized).

Ambulatory Surgical Center — 

A facility that mainly provides outpatient surgery. These centers must: (i) be staffed by practitioners and nurse under the supervision of a physician; (ii) have permanent operating and recover rooms; (iii) be staffed and equipped to giver medical emergency care; and (iv) have written back-up arrangements with a local hospital of medical emergency care. Horizon BCBSNJ will recognize if it carries out its stated purpose under all relevant state and local laws, and it is either (i) accredited for its stated purpose by either the Joint Commission or the Accreditation Association for Ambulatory Care; or (ii) approved for its stated purpose by Medicare. Horizon BCBSNJ does not recognize a facility as an Ambulatory Surgical Center if it is part of a hospital.

Anniversary Date — 

The date on which coverage under a group or individual contract became effective.

Anniversary Year — 

Generally, the 12-month period based on a group or individual contract's anniversary date.

Applied Behavior Analysis Certified Therapist — 

A practitioner that uses learning techniques and positive reinforcement to bring about meaningful and positive change in behavior.

Assignment of Benefits — 

When a member authorizes their health benefits plan to directly pay a health care provider for covered services.

Audiology — 

A specialty focusing on hearing disorders through identification and evaluation of hearing loss, and the rehabilitation of persons with hearing loss.

Away from Home Care — 

A national Blue Cross and Blue Shield Association program that offers Health Maintenance Organization (HMO) members access to a participating HMO health care professional out of the Horizon BCBSNJ service area, which is the state of New Jersey and certain bordering areas. The program is designed for members who have a child attending school out of the Horizon BCBSNJ service area, have dependents living in different service areas, have a long-term work assignment in another state and/or are a retiree with dual residence.

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