i Table of Contents Introduction.................................................................................................................................1 Part 1 Member Services............................................................................................................2 Your Primary Care Provider ..................................................................................................................2 Your Health Care Network ....................................................................................................................2 Your Identification Card ........................................................................................................................3 How to Get Help for Questions..............................................................................................................4 Discrimination Is Against the Law ........................................................................................................4 Your Rights under Mental Health Parity Laws......................................................................................5 How You Can Request an Estimate for Proposed Covered Services ....................................................5 Delivery of Summary of Payments Forms.............................................................................................7 The Office of Patient Protection ............................................................................................................7 Part 2 Explanation of Terms ......................................................................................................8 Allowed Charge (Allowed Amount)......................................................................................................8 Appeal..................................................................................................................................................11 Balance Billing.....................................................................................................................................11 Benefit Limit........................................................................................................................................11 Blue Cross Blue Shield HMO Blue .....................................................................................................12 Coinsurance..........................................................................................................................................12 Copayment ...........................................................................................................................................12 Covered Providers................................................................................................................................13 Covered Services..................................................................................................................................14 Custodial Care......................................................................................................................................14 Deductible............................................................................................................................................14 Diagnostic Lab Tests............................................................................................................................15 Diagnostic X-Ray and Other Imaging Tests........................................................................................15 Effective Date ......................................................................................................................................15 Emergency Medical Care.....................................................................................................................15 Grievance .............................................................................................................................................16 Group ...................................................................................................................................................16 Group Contract.....................................................................................................................................16 Individual Contract ..............................................................................................................................17 Inpatient ...............................................................................................................................................17 Medical Policy .....................................................................................................................................18 Medical Technology Assessment Criteria ...........................................................................................18 Medically Necessary (Medical Necessity)...........................................................................................19 Member................................................................................................................................................19 Mental Conditions................................................................................................................................19 Mental Health Providers ......................................................................................................................20 Out-of-Pocket Maximum (Out-of-Pocket Limit).................................................................................20 Outpatient.............................................................................................................................................20 Plan Sponsor ........................................................................................................................................21 Plan Year..............................................................................................................................................21