An individual who is authorized by Provider to accept the PROVIDERnet Terms & Conditions, register for a PROVIDERnet account, use PROVIDERnet or PROVIDERnet account information and submit Claims, in each case on behalf of Provider.

Any applicable: (a) statute, law, regulation, principle of common or civil law or equity, rule, municipal by-law, or other requirement having the force of law; and (b) bylaw, policy, practice, standard, code of ethics or conduct, and guideline of any body, board, agency, college or council responsible for the licensing and regulation of services provided by a Practitioner in the jurisdiction where such services are or will be provided.

A request for reimbursement of the Eligible Expense portion of an expense submitted on behalf of a Member.

The portion of a Claim that must be paid by the Member as a condition of Pacific Blue Cross paying an Eligible Expense.

The coordination of claims payment where a Member has coverage under more than one Plan, determined in accordance with applicable industry guidelines, including the Canadian Life and Health Insurance Association Guideline G4 – Group Health and Dental, as amended from time to time.

The amount the Member must pay before Pacific Blue Cross will make any payment for an Eligible Expense under a Policy.

A charge incurred by a Member for Services or Equipment covered under a Policy as a benefit.

Electronic funds transfer is an electronic delivery of claim payments, directly deposited into the Provider's designated bank account on the day the payment is issued.

Equipment, products or supplies purchased by a Provider on behalf of a Member or by a Member from a Provider.

Any service that directly relates to acquiring, delivering or using Equipment.

A written statement displaying all the details of the claims paid and not paid resulting from a request. EOBs can be issued on paper or electronically.

Any actual or potential Claims that may be related to fraud, criminal conduct, willful misconduct or a breach of the PROVIDERnet Terms & Conditions, whether by an Administrator, Practitioner, Provider, Member or another Person, and whether acting alone or together with others.

This reference guide.

A Spouse, child, parent or sibling of a Provider or Practitioner or a person who is ordinarily resident in the home of a Provider or Practitioner.

Money paid to a Provider in connection with a Claim that was not to reimburse an Eligible Expense as determined by Pacific Blue Cross or in connection with a Claim arising from or related to a breach of the PROVIDERnet Terms & Conditions.

A physical place of business at which a Provider offers Services or Equipment. Each Location is associated with a unique Provider ID issued by Pacific Blue Cross. A Provider may operate multiple Locations, and a Practitioner may provide Services at one or more Locations.

The primary individual eligible under a Policy to be reimbursed for Eligible Expenses and the dependents of such individual who are eligible under such individual's Policy to be reimbursed for Eligible Expenses.

Any individual, corporation, limited liability company, unlimited liability company, body corporate, partnership, limited liability partnership, firm, joint venture, syndicate, association, capital venture fund, trust, trustee, executor, administrator, legal personal representative, estate or governmental authority.

Has the meaning set out in Applicable Laws, including the Personal Information Protection Act, SBC 2003, c.63, the Freedom of Information and Protection of Privacy Act, RSBC 1996 c.165 and the Personal Information Protection and Electronic Documents Act, SC 2000 c.5, and includes information about an identifiable individual.

A benefits contract under which a Member is eligible to receive coverage for health benefits, whether administered by Pacific Blue Cross or by another insurer or administrator.

An entity that has entered into a contract with Pacific Blue Cross for the provision or administration of benefits to a Member under a Policy.

An individual, group or government funded benefit contract insured or administered by Pacific Blue Cross.

An individual who is licensed or registered in accordance with Applicable Laws to provide certain services to the public, and who is registered with, or in the process of being registered with, Pacific Blue Cross to provide Practitioner Services.

Any services provided directly by a Practitioner to one Member.

An individual authorized in accordance with Applicable Laws to issue a Prescription.

A written order for the use by a Member of a drug, Equipment or Service issued by a Prescriber.

An access designation available to an Administrator that provides the highest level of permissions for a Provider’s PROVIDERnet account. Each Provider must have one (1) and only one Primary Account Access holder. The Primary Account Access holder may view, set up, and modify the Provider’s banking information for the purpose of receiving payments (including direct deposit), and may perform all functions available to Standard Account Access holders.

A Person who registers for a PROVIDERnet account and who receives or will receive payments in respect of Claims for Eligible Expenses from Pacific Blue Cross on behalf of Members, and for greater certainty a Provider who is an individual may also be a Practitioner.

The unique Provider identification number issued by Pacific Blue Cross to a Provider upon successful registration as a Pacific Blue Cross Provider.

The terms and conditions governing access to and use of PROVIDERnet, as amended by Pacific Blue Cross from time to time, and accepted during registration, in connection with the submission of Claims through PROVIDERnet, and through continued use. See PROVIDERnet Terms & Conditions.

Equipment Services and Practitioner Services.

An access designation available to an Administrator that permits use of a Provider’s PROVIDERnet account to perform operational functions, including viewing pre-authorizations, submitting Claims, and accessing Claims history. A Provider may have one or more Standard Account Access holders. Standard Account Access does not include the ability to view, set up, or modify banking information associated with the Provider.

All documents, records and information arising from or related to a Claim, including treatment plans, invoices, receipts, appointment records, prescriptions, Member charts, inventory management records, Provider personnel and Practitioner scheduling records, Prescriptions, and Personal Information.