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Terms in this set (16)
The maximum fee that a third party will reimburse a provider for a given service
Any necessary, reasonable and customary item of expense, that a part of the cost that is covered by the member's plan or another plan, other than Medicare
Provider practice of billing the patient for the difference (or balance) of charges above the amount reimbursed by the health plan. Managed care plans commonly prohibit provideres from balance billing except for allowed copayments, coinsurance, & deductibles
To separately purchase services that are typically part of a managed care package. For example, an HMO may "carve out" the vision care benefit and select a specialized vendor or supply these services on a stand alone basis
This option provides nurse coordiantors to handle high-cost claims and recommend specialized care and services targeted to an individual's treatment goals and needs. It is used to deal with catastrophic illnesses, such as major head trauma, severe stroke, spinal cord injury, high-risk infants, mulitple fractures, servere burns, and amputations.
Those specific health care charges that an insurer will consider for payment under the terms of a health insurance policy.
CUT - Correspondence Unit Tracking
This is the internal documentation system in the OAO system. Memeber Services tracks all incoming correspondence via phone, fax, or other correspondence within CUT. Other SIHO departments also use CUTs to track their interactions with members, providers, brokers, accounts or agents. CUTs have the ability to be reassigned so that another area can receive a CUT and complete the request (eg: claims reprocessing, mailing of ID cards)
The indentification of a disease or condition through an examination
Diagnosis-Related Groups (DRGs)
A system used by Medicare and other insurers to classify illnesses according to diagnosis and treatment. Medicare inpatient hospitals operating costs are determined in advance and paid on a per-case basis, according to fixed amount or weight established for each DRG
EOB - Explanation of Benefits
Worksheet that explains the claim payment to the member and health care provider
Multi-County Physicians (MCP)
It is an independent practice association for physicians and oral surgeons who work in the areas that SIHO serves. Its Board of Directors appoints six of its members to the SIHO Board of Directors
Cost control procedure that requires a service be approved in advance by the physician and/or health plan. Without preauthorization, the plan will not pay for the services. Also called prior authorization.
Primary Care Physicians (PCP)
Is a family practice physician, a pediatrician or a general internal medicine physician. The primary care physician provides, coordinates and/or is actually aware of all aspects of the member's health care and history
Summary Plan Description (SPD)
The description of benefits under which the employer's self-funded health and welfare plan is administered
Apply deductible & coinsurance between both plans ans pay no more than 100%
A system whereby an employer must pay, or provide insurance to pay, the lost wages and medical expenses of an employee who is injured on the job
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