Glossary

B

Balance Billing — 

The bill a health care provider sends a member for charges that exceed the allowable charge. Under some Horizon BCBSNJ plans, if a member receives health care services from a health care provider that is not in Horizon BCBSNJ’s network, they have to pay billed amounts above the allowable charge.

Behavioral Health Office Visit — 

An appointment with a behavioral health specialist, such as a licensed counselor, psychologist or psychiatrist.

Benefit — 

The coverage that a Horizon BCBSNJ plan provides for covered services and/or supplies.

Benefit Period — 

A specified period of time during which a particular plan feature will apply. Benefit periods are usually a one-year period, but may not be a calendar year (January 1 to December 31). For example, a plan may limit visits to a physical therapist to 30 during any benefit period, as defined. The first benefit period begins on the members’ coverage date. The last benefit period ends when the member is no longer covered.

Billed Amount — 

Amount charged by the doctor or health care professional for each service on the claim.

BlueCard® PPO — 

The BlueCard® PPO program is the premier national Blue Cross and/or Blue Shield Preferred Provider Program that links together more than 600,000 network doctors and 6,000 network hospitals in 48 states. This is a seamless network that affords members the ability to use any network doctor or network hospital in any location. For instance, a member living in Florida can use network providers in Georgia or any other state. The network also includes hospitals and doctors abroad so members can access care when traveling internationally.

No PCP or Referral Needed: Members do not need to select a Primary Care Physician (PCP), and referrals are not needed to access specialty care. Under BlueCard® PPO members can access any participating network doctor or hospital at any time at the in-network level of benefits. Members can also use any BlueCard® PPO participating doctor or hospital not in the network and receive an out-of-network level of coverage.

In- and out-of-network benefits: In- and out-of-network levels of benefits vary depending on each member's group medical benefits. Typically, members receive a greater level of coverage when using BlueCard® PPO providers. Members should check with their employer or contact the Horizon BCBSNJ service line for additional information about their benefits.

Easy service: Members have no claim forms to file and virtually no paperwork. All BlueCard ®PPO Providers handle all of the paperwork. Horizon BCBSNJ offers toll-free customer service Monday through Friday, 8 a.m. to 8 p.m., Eastern Time. Members can also access information via Member Online Services.

Locate a BlueCard ® PPO Provider: Members can access BlueCard ® PPO network doctors and hospitals several ways. Members can access information about network providers, including directions to their location, using the BlueCard Physician Finder. Members can also call the BlueCard Access Line at 1-800-810-BLUE (2583) to access PPO providers. If you are not yet an enrolled member, indicate that you are not yet enrolled but are considering becoming a member.

Portable Benefits Coverage: Whether traveling (business or vacation) or living in another state (student away at college), members can access care by presenting their Horizon BCBSNJ member ID card to any participating doctor or hospital. The member ID card is easily identifiable by the “suitcase” logo, and lists the toll-free number to reach a BlueCard ® PPO provider.

A BlueCard ® [PPO/POS] provider is a provider not located in New Jersey that has a written agreement with another BCBS to provide care to both that plan or company’s members and other BCBS members. For purposes of the BlueCard ® Program, a BlueCard [PPO/POS] provider is both an in- and out-of-network provider.

BlueCard® Program — 

A national program established by the Blue Cross and Blue Shield Association that enables Horizon BCBSNJ members to access Covered Services and/or Supplies outside the geographic area that Horizon BCBSNJ serves.

Board Certification — 

Means that a doctor or other health care professional has met the requirements of the American Board of Medical Specialties, American Osteopathic Association or another Horizon BCBSNJ-recognized board, depending on the specialty. To become board certified, a doctor or other health care professional must:
  • Graduate from an accredited professional school
  • Complete specific training in a specialty Practice in that specialty for a specified amount of time
  • Pass a written test

Most boards require doctors or other health care professionals to be periodically recertified. We check specialty board certification before a doctor or other health care professional joins our network(s) and at least every 36 months after that or more often according to state or federal requirements.

Bone Density Scanning (DXA) — 

Also called dual-energy X-ray absorptiometry (DXA) or bone densitometry is an enhanced form of X-ray technology that is used to measure bone loss. DEXA is today's established standard for measuring bone mineral density (BMD).

Brand Name Drug — 

Drugs, as determined by the federal Food and Drug Administration (FDA), which are manufactured by a pharmaceutical company that has patented the drug’s formula and is protected by the registered trademark of the pharmaceutical company that produces them.

Breast MRI — 

Magnetic resonance imaging (MRI) of the breast uses a powerful magnetic field, radio waves and a computer to produce detailed pictures of the structures within the breast.

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