Glossary

We recognize that some of the terms we’ve used on this website and in our letters may not be familiar. Below you can find a glossary of terms that we’ve compiled to help explain what each of the key elements means.

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  • Term
    Definition
  • A financial payment made by your health plan for covered services or drugs.
  • A fixed dollar amount you must pay with your own money for medical services, such as office visits, or prescription drugs.
  • The health care costs that are your responsibility to pay, including deductibles, copays, coinsurance, and other costs not covered by your health plan.
  • The costs your health plan pays for your medical services or prescription drugs.
  • The amount you must pay each year – with your own money – before your health plan begins paying benefits.
  • An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
  • A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
  • Care provided in a hospital that usually doesn’t require an overnight stay.
  • Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
  • BlueCross BlueShield of Tennessee has a contract with that provider. When you are in-network, you will receive a discounted rate for the services you receive.
  • The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan.  In-network co-insurance usually costs you less than out-of-network co-insurance.
  • A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
  • A group of doctors, hospitals and other health care providers contracted to provide services to health plan members at a rate that is less than their usual fees.
  • A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
  • BlueCross BlueShield of Tennessee does not have a contract with that provider. Providers who aren’t in our network don’t offer a discount, so their rates are higher. For most plans, if you see a provider who is not in your network, you will likely have to pay more.
  • The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
  • A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan.  Out-of-network copayments usually are more than in-network co-payments.
  • A doctor with whom your health plan does not have a contract. If your plan allows you to receive covered services from a doctor or other provider outside your network, you may pay a higher share of the costs.
  • The amount you must pay out of your own pocket for your medical or prescription drug expenses. These costs include things like deductibles, coinsurance or copays.
  • The most you will pay with your own money – or out of your own pocket – in a year.
  • Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
  • A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
  • A health care provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.  Your health insurance or plan may have preferred providers who are also “participating” providers.  Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
  • A network of doctors, caregivers and medical facilities that agree to provide health care services to our members at a lower cost; members get the most from their PPO plan when network providers are used.
  • The monthly payment made for an insurance policy.
  • A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
  • A health care provider specializing in family practice, internal medicine, general practice, pediatrics, obstetrics or gynecology, or a physician assistant or nurse practitioner.
  • Any doctor, health care practitioner (nurse, physician assistant, etc.), hospital, facility or pharmacy that provides you with medical services or prescription drugs.
  • A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
  • Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not as severe as to require emergency room care.