Glossary

C

Cardiac CT — 

A heart-imaging test that uses CT technology with or without intravenous (IV) contrast (dye) to visualize the heart anatomy, coronary circulation, and great vessels, which includes the aorta, pulmonary veins and arteries.

Cardiothoracic Surgery — 

A specialty focusing on operative, perioperative care and critical care of patients with pathologic conditions of the chest.

Case Management — 

The coordination of services to help meet a member’s health care needs, usually when a member has a condition that requires multiple services from multiple health care professionals. This term is also used to refer to the coordination of a member’s care during and after a hospital stay.

Certified Nurse Practitioner — 

A registered nurse who has completed an advanced training program in a medical specialty such as family practice, pediatrics or internal medicine. A nurse practitioner may function as a primary health care professional and prescribe medication.

Child and Adolescent Psychology — 

Clinical child psychology is a specialty in professional psychology that develops and applies scientific knowledge to the delivery of psychological services to infants, toddlers, children and adolescents within their social context.

Chiropractic — 

A specialty focusing on the nonsurgical treatment of neuromuscular skeletal conditions by means of manipulation of the spine and related structures.

Chronic Disease or Chronic Condition — 

A chronic disease or condition is one that is long lasting or recurs.

Coinsurance — 

The percent applied to covered charges (not including deductibles) for certain covered services and/or supplies in order to calculate benefits under the program. The term does not include copayments. For example, under an 80/20 plan, Horizon BCBSNJ would pay 80% of the allowable charge and a member would pay 20%. The 20% paid by the member is the coinsurance.

Colon/Rectal Surgery — 

A specialty focusing on the diagnosis and treatment of disorders of the colon, rectum and anal canal.

Comprehensive Outpatient Rehabilitation Facility — 

A medical facility that provides outpatient diagnostic, therapeutic and restorative services for rehabilitation of injury or illness.

Computed Tomography (CT) — 

CT is a diagnostic imaging test used to create detailed images of internal organs, bones, soft tissue and blood vessels.

Computed Tomography Angiography (CTA) — 

CTA uses an injection of iodine-rich contrast material and CT scanning to help diagnose and evaluate blood vessel disease or related conditions, such as aneurysms or blockages.

Concurrent Review — 

A program where Horizon BCBSNJ conducts a review during a member’s facility stay, monitoring the medical treatment to ensure that services are medically necessary and eligible for coverage.

Contract Year — 

Usually, a period of 12 months, starting the first day of a given month.

Contracting Provider — 

Any licensed or certified doctor or other health care professional of health care services who has signed an agreement to accept Horizon BCBSNJ's allowance as payment-in-full for covered services. Types of contracting providers include (but are not limited to) hospitals, medical care facilities, pharmacies, ambulatory surgical centers, doctors, other licensed or certified practitioners (as described in the contract) and providers of ambulance services.

Coordination of Benefits (COB) — 

If a member is eligible to receive benefits under the Horizon BCBSNJ plan and another group health plan, Horizon BCBSNJ coordinates benefits with the other plan. Coordination of benefits means one health plan pays first (is primary) and one plan pays second (is secondary). This prevents overpayment of charges. When coordinating benefits, the total payment to a health care provider will not be more than 100% of the provider’s charge.

Copayment — 

A predetermined fee a member pays for each doctor’s office visit, medical service or prescription and/or other covered services and/or supplies, as described in the contract. For example, a health plan may have a $10 copayment for doctor office visits. This means every time a member visits a doctor, he or she would pay $10. A copayment may be in addition to other cost-sharing features (e.g., a deductible).

Cost Sharing — 

Dividing the cost of health care among members, insurance companies, employers and health care providers. Horizon BCBSNJ pays part of the health care bills, and a member pays part.

Counselors — 

Mental health professionals who provide counseling and therapy.

Coverage Tier — 

The Affordable Care Act establishes four levels of coverage based on the concept of “actuarial value,” which represents the share of health care expenses the plan covers for a typical group of enrollees. As plans increase in actuarial value – bronze, silver, gold, and platinum – they would cover a greater share of enrollees’ medical expenses overall, though the details could vary across plans.

Covered Service and/or Supplies — 

The types of services and supplies described in the covered services and/or supplies section on the group’s contract. The services and supplies must be (a) furnished or ordered by a providers; and (b) for preventative care, or medically necessary and appropriate to diagnose or treat an illness (including mental or nervous disorders, group therapy, and substance use disorders as defined by the American Psychiatric Association, recognized by Horizon BCBSNJ, and stated by law) or injury.

Critical Access Hospital — 

A hospital that already participates in Medicare; be located in a state that established a state rural health plan for the State FlexProgram; be located in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural; furnish 24-hour emergency care services seven days a week, using either on-site or on-call staff, with specific on-site response timeframes for on-call staff; maintain no more than 25 inpatient beds that may also be used for swing bed services. It may also operate a distinct part rehabilitation and/or psychiatric unit, each with up to 10 beds; have an annual average length of stay of 96 hours or less per patient for acute care.

Critical Care Medicine — 

The direct delivery by a doctor(s) of medical care for a critically ill or injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that the patient’s survival is jeopardized.

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