Glossary

Assignment of benefits

A clause in a benefits policy that allows the plan member to direct the payment by Alberta Blue Cross^® directly to a dentist or other service provider. The plan member does this by signing the assignment box on the top right hand corner of the claim form. Not all benefits can be paid on assignment. Contact Customer Services for verification of what products and services can be paid through assignment.

Claim

A form with supporting receipts or information sent in for assessment.

Claim statement

The statement is not a bill, but merely an explanation of how a claim was processed. This statement is mailed to a member to explain how and why a claim was or was not paid. If you have other coverage, you may submit this form to your secondary health plan for consideration.

Coinsurance

The percentage of a claim for products or services payable by Alberta Blue Cross^® (e.g. drugs could be covered at 80 per cent)

Co-pay

The percentage of a claim for products or services payable by the plan member. A provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 per cent. Any additional costs are paid by the member out of pocket.

C.O.B. (Coordination Of Benefits)

A process where individuals, couples or families with more than one benefits plan combine their benefits coverage. This allows a plan member to have coverage for up to 100 per cent of the dollar value for eligible prescription drug, dental and health services benefits.

D.I.N. (Drug Identification Number)

The number located on the label of prescription that has been evaluated by the Therapeutic Products Programme (TPP) and approved for sale in Canada. A DIN lets the user know that the product has undergone and passed a review of its formulation, labeling and instructions for use.

D.O.N. (Determination of Needs Form)

This form is filled out by a physiotherapist when an assessment is done on the first visit.

Fee Schedule

A schedule that a plan follows for payment (e.g. for dental procedures).

L.C.A. (Least Cost Alternative)

When you have an Alberta Blue Cross^® plan with LCA pricing, the pharmacist will dispense the lower-priced alternative, rather than the brand name product. This will occur only when there is a brand name product and generic alternative product with the same active ingredients.

Primary plan

When the patient is covered by two plans, the plan that is billed first is the primary plan. Determining the primary and secondary plans for individuals with multiple plans depends on your coverage. Please see the Coordination of Benefits brochure available on this web site for information on determining which plan is primary and which is secondary.

Provider

The professional who provided the service or product (e.g. a doctor, dentist or pharmacist).

Provincial Maximum Reached letter

A letter from the Provincial Health Plan finding that the maximum dollar amount for services has been reached during the benefit period.

Treatment Plan

The dentist notifies Alberta Blue Cross^® of the treatment plan before work begins. We will estimate the benefits that will be paid and notify the plan member. Also known as a predetermination, preauthorization or preauth.

Secondary plan

When a patient is covered by two plans, the plan that is billed second is the secondary plan, and pays the outstanding balance for eligible expenses.