Glossary
Here are some terms you may find on this website or in your member handbook.
A
Appeal
A request for your managed care organization to review services that were denied or terminated.
B
C
Complaint
An expression of dissatisfaction expressed orally or in writing to the managed care organization.
Copayment
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
D
Durable Medical Equipment (DME)
Equipment ordered by a health care provider for everyday or extended use. Coverage for DME may include, but is not limited to: oxygen equipment, wheelchairs, crutches, or diabetic supplies.
E
Emergency Medical Condition
An illness, injury, symptom, or condition that is sudden and severe. Emergencies can damage bodily functions or body organs. Without immediate medical help, your health and life could be in danger.
Emergency Medical Transportation
Ground or air ambulance services for an emergency medical condition.
Emergency Services
Care you get in an emergency room to stop a severe medical condition from getting worse.
Excluded Services
Health care services that your health insurance or health plan may not cover.
F
G
Grievance
A formal, written complaint to the managed care organization that requires further review.
H
Habilitation Services and Devices
Health care services, such as physical or occupational therapy that help a person keep, learn, or improve skills and functioning for daily living.
Home Health Care
When a health professional visits you at home. They usually track your ongoing health issues or your recovery after a hospital stay.
Hospice Services
Services that provide comfort and support for people in the last stages of a terminal illness and their families.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
I
In-Network Provider
A provider who has a contract with your health plan to provide covered services to you. A participating provider is also known as an in-network provider.
J
K
L
M
Managed Care Organization (MCO)
A health plan contracted by HHSC to deliver Medicaid and CHIP benefits to members.
Medically Necessary
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. BCBSTX covers all medically necessary care that Medicaid covers.
N
Network
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
O
Out-of-Network Provider
A provider who is not contracted with your health plan to provide covered services to you. It may be more difficult to obtain prior authorization from BCBSTX if you go to an out-of-network provider. In some cases, such as when there are no other providers, BCBSTX can contract to pay a provider that is not in our network. An out-of-network provider is also known as a non-participating provider.
P
Plan
A benefit, like Medicaid, which provides and pays for your health care.
Prescription Drugs
Drugs and medications require a prescription by law. For STAR and CHIP members, your plan covers prescription drugs that are on your Preferred Drug List.
Primary Care Provider (PCP)
A PCP is your personal doctor who will give you most of your care. PCPs can be a Medical Doctor (M.D.), Doctor of Osteopathic Medicine (D.O.) or other health care provider who is licensed, certified or accredited, as required by state law.
Prior Authorization
Some services for health care and certain drugs require approval from Blue Cross and Blue Shield of Texas. This approval is called “prior authorization.” If BCBSTX does not approve the services or drugs, the costs will not be covered (paid for) by BCBSTX.
Provider
A provider is a licensed doctor, facility, or health care professional. Your PCP is a provider. Providers offer medical services and treatment to health plan members.
Provider Services
Health care that is coordinated by a licensed medical provider. This care may be handled by a Medical Doctor, Doctor of Osteopathic Medicine, Nurse Practitioner, or other health care provider.
Q
R
Rehabilitation Services and Devices
Health care services, such as physical or occupational therapy, that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
S
Skilled Nursing Care
Skilled nursing or rehab care that is supplied by licensed health professionals, like nurses, and physical therapists. This care is often given after an injury, surgery or to help you manage life-long sickness.
Specialist
A specialist is a provider who is a trained expert on a specific area of health. This may be a certain system in your body, a disease or a treatment.
T
U
Urgent Care
Urgent care includes health services for an illness, injury or condition that you need immediate attention for. However, it isn’t serious enough to go to an emergency room (ER) for.
