2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 10. Definitions of Terms We Use in This Brochure
Page 138
Sound natural tooth
A tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.

Specialty drugs
Pharmaceutical products that are included on the FEP Blue Focus Specialty Drug List that are typically high in cost and have one or more of the following characteristics:

  • Injectable, infused, inhaled, or oral therapeutic agents, or products of biotechnology
  • Complex drug therapy for a chronic or complex condition, and/or high potential for drug adverse effects
  • Specialized patient training on the administration of the drug (including supplies and devices needed for administration) and coordination of care is required prior to drug therapy initiation and/or during therapy
  • Unique patient compliance and safety monitoring requirements
  • Unique requirements for handling, shipping, and storage

A Carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from the Carrier’s health benefits plan.

Telehealth dermatology
Under the telehealth benefit, dermatologic conditions seen and treated include but are not limited to acne, dermatitis, eczema, psoriasis, rosacea, seborrheic keratosis, fungal infections, scabies, suspicious moles, and warts. Members capture important digital images, combine those with the comprehensive questionnaire responses, and send those to the dermatology network without requiring a telephone or video interaction.

Telehealth services
Non-emergency services provided by telephone or secure online video/messaging for minor acute conditions (see page 134 for definition), dermatology care, and behavioral health and substance use disorder counseling, nutritional counseling. Go to www.fepblue.org/telehealth or call 855-636-1579, TTY: 855-636-1578, toll free to access this benefit. After your telehealth visit, please follow up with your primary care provider or specialist.

Transplant period
A defined number of consecutive days associated with a covered organ/tissue transplant procedure.

Urgent care claims
A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will judge whether a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our customer service department using the telephone number on the back of your ID card and tell us the claim is urgent. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

“Us,” “we,” and “our” refer to the Blue Cross and Blue Shield Service Benefit Plan, and the local Blue Cross and Blue Shield Plans that administer it.