Primary Care Physician (PCP)
This is a doctor who has contracted with a managed care plan and has agreed to be responsible for providing the health care for specific patients participating in the plan. Each patient with a managed care plan must choose a PCP from a list, or directory, of physicians who are providing services for the plan. Under the terms of most managed care plans, the patient must contact his or her PCP before he or she receives care from any other health care provider (except in the case of an emergency). Because the PCP is required to monitor and administer the health care of the plan's patients, the PCP is often referred to as the "Gatekeeper" of managed care.
This is an amount each patient is required to pay for a particular service he or she receives from the physician or other managed care plan and each patient's type of coverage. For example, most plans require a Visit Copay which is a flat amount (usually between $10.00 and $20.00) the patient pays each time he or she visits the doctor. Many plans also require Procedure Copays. Which are copayments required for specific procedures (e.g. surgery, radiographs).
A process insurance companies use to verify whether or not a procedure was medically necessary to treat the patients complaint/problem.
This is the practice scheduling more patients than the physician can see during reasonable period of time. Overbooking may also be called double scheduling or double booking.
National Provider Identifier (NPI)
Is a 10-digit numeric identifier that replaces health care provider indentifiers (legacy numbers) in HIPPA standard transactions.
This is a printed list of the most common procedures and treatment performed by the doctor. The doctor uses this paper form to indicate the procedure(s) or treatment performed for the patient as well as the diagnosis for the patient's condition. also see Superbill
This is the amount the patient is expected to pay before the insurance plan will begin paying. The deductible is used when a patient is expected to pay a portion of their medical expenses. For example, the charges for a patient's visit may total $120.00. However, because the patient's deductible for this plan is $100.00 annually, the insurance company will be billed only for the remaining $20.00, whereas the patient will have to pay the $100.00 deductible amount.
A list of information that appears when "?" and ENTER are are pressed at a field. or when the user clicks on the Help btton ("?") on the top toolbar. The user may choose from the information in the list to complete the field in question. Examples of the help window are the Zip Code Help Window, the Procedure Code Help Window, and the Refferring Doctor Help Window.
A term used to verify the patient's eligibility for insurance benefits.
A system of payment used by managed care plans where health care providers are reimbursed a fixed amount per capita (per person) enrolled over a given or contracted period of time. Regardless of the type or number of services rendered. A variety of capitation plans ranging from fixed payment per procedure code to a fixed amount paid per claim.