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P.O. Box 805107

Chicago, IL 60680 Appeals and Grievances

P. O. Box 4288 Scranton, PA 18505

Medicare Appeals and Grievances Appeals Fax: 855-674-9185 Grievances Fax: 855-674-9189 Blue Medicare RX

MAPD Pharmacy Help Desk

800-693-6704

CMS Website Address www.cms.gov

Section 12: Glossary of Terms

Term

Description

Appeal Any of the actions or procedures that involve a request for review of adverse

organization determinations pertaining to health care services received, or any amounts that the Member must pay for a covered service (including prescription drugs).

Certificate of Coverage The document(s) which describe the health benefits coverage available to Members enrolled in a BCBSIL MA PPO Plan.

Covered Services Those health care benefits which are available to the Member enrolled in the

BCBSIL MA PPO Plan and described in the Member’s Certificate of Coverage.

Emergency Medical Condition Medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition,

sickness or injury is of such a nature that failure to receive immediate medical care could result in:

 Serious jeopardy of the patient’s health;  Serious impairment of bodily functions;

 Serious dysfunction of any bodily organ or part;  Serious disfigurement; or

 Serious jeopardy to the health of the fetus, in the case of a pregnant

patient.

Emergency Services These are Covered Services that are needed to evaluate or stabilize an

Emergency Medical Condition and which are furnished by a Provider qualified to furnish services to individuals experiencing an Emergency Medical

Condition.

Hospital A Medicare-certified institution licensed in a State, which provides inpatient,

outpatient, emergency, diagnostic and therapeutic services. The term “Hospital” does not include a convalescent nursing home, rest facility or facility for the aged which furnishes primarily custodial care, including training in routines of daily living.

Medicare The Federal Government health insurance program established by Title XVIII

of the Social Security Act.

Medicare Part A Part A includes benefits for Hospital insurance benefits including inpatient

Hospital care, skilled nursing facility care, home health agency care and hospice care offered through Medicare.

Medicare Part B Part B includes benefits for Physician services (in both Hospital and non-

Hospital settings) and services furnished by certain non-Physician practitioners. Other Part B services include lab testing, durable medical equipment, diagnostic tests, ambulance services, prescription drugs that cannot be self-administered, certain self-administered anti-cancer drugs, some other therapy services, certain other health services, and blood not covered under Part A.

Medicare Advantage (MA) Plan

A policy or benefit package offered by an MA organization under which a specific set of health benefits offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the Service Area

covered by the MA organization. An MA organization may offer more than one benefit plan in the same Service Area. In many cases, MA Plans also offer Medicare Part D (prescription coverage). These plans are called MA Plans with Prescription Drug Coverage (MAPD).

Member A Medicare beneficiary entitled to receive Covered Services who has

voluntarily elected to enroll in a BCBSIL MA PPO Plan and whose enrollment has been confirmed by CMS.

Participating IPA Any duly organized Individual Practice Association, Independent Physician

Association, organized Medical Group, Physician Hospital Organization or other legal entity organized to arrange for the provision of professional medical service which has in force a contract or agreement with BCBSIL to provide professional and ancillary services to Members enrolled in BCBSIL as outlined in BCBSIL Provider Manual and according to the Member’s plan of benefits outlined in his or her Certificate of Coverage.

Participating Provider A Hospital facility, health care facility, laboratory, Physician, person or other Provider of medical services which has a written agreement with Participating IPA at the time Covered Services are provided to Members and that is duly licensed by the appropriate state and local authority to provide such services.

Physician Any person currently licensed to practice medicine or osteopathy in the state

in which the person maintains their office.

Primary Care Physician Any IPA Physician who has been selected by the Member to be primarily

responsible for treating and coordinating the Member’s health care needs. A PCP may be a Physician who is Board Certified or Board Eligible in Internal Medicine, Family Practice, General Practice or Geriatric Medicine.

Provider Any Physician or health care practitioner, to include, but not limited to, a

Physician, physical therapist, psychologist, hospital facility, health care facility, laboratory and any other provider of medical services, licensed in accordance with all applicable Laws.

Provider Manual This booklet which describes the requirements and responsibilities of

Participating IPAs and their Providers who have agreed to participate in the BCBSIL MA PPO network.

Quality Improvement Organization (QIO)

Organizations comprised of practicing doctors and other health care experts under contract to the federal government to monitor and improve the care given to MA members and Medicare enrollees. QIOs review complaints raised by MA members about the quality of care provided by Physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans and ambulatory surgical centers. The QIOs also review continued stay denials for enrollees receiving care in acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs and CORFs. KEPRO in Area 4 located at 5201 W. Kennedy Blvd., Suite 900, Tampa, FL 33609 is the QIO for BCBSIL.

Reconsideration A BCBSIL MA Member’s first step in the Appeal process after an adverse

organization determination. BCBSIL or an independent review entity may re- evaluate an adverse organization determination, the findings upon which it was based and any other evidence submitted or obtained.

Representative An individual appointed by a BCBSIL MA PPO Plan Member or other party,

or authorized under State or other applicable law, to act on behalf of the Member or other party involved in an Appeal or grievance. Unless otherwise stated, the representative will have all of the rights and responsibilities of the Member or party in obtaining an organization determination, filing a

grievance, or in dealing with any of the levels of the Appeals process, subject to the applicable rules described at 42 CFR Part 405.

Service Area A geographic area approved by CMS within which an eligible individual may

enroll in a MA Plan. The geographic area for the BCBSIL MA PPO Plan includes Cook, DuPage, Kane and Will Counties within the State of Illinois.

HEDIS is a registered trademark of NCQA.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement,

representations or warranties regarding any products or services offered by independent third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.