Provider Contracting Basics
What is the term for the agreement between a provider and a health plan outlining reimbursement rates?
What is a provider contract?
What is the main goal of network adequacy?
To ensure members have access to care within reasonable time and distance.
If I need to communicate with HR that I am working from home, where can I report this information?
What is INFOR?
Which law protects patient health information?
HIPAA.
Who has been with CHRISTUS for double digit years?
LaTasha & Jackie
What does “effective date” in a contract signify?
When the contract terms begin.
What is the term for ensuring a health plan has enough providers to meet member needs?
What is network adequacy.
If I want to identify how a gap was created, where can I find this information, specifically?
Quest>LOB tile>Specialty/County>Network Services providers>identify who was removed from the last refresh.
What is the term for the process of verifying provider credentials?
Credentialing.
Which Team members are LA natives?
Chemeeka & Jennifer
What is the process called when a provider is evaluated before joining a network?
What is Credentialing?
This line of business normally has a higher rate than the others on a template agreement.
Commercial line of business
Where can I complete my flu questionnaire each year?
What is ReadySet?
Which federal program sets standards for Medicare Advantage
CMS regulations
Who has a goal of visiting every football stadium at least once.
Tasha
What is the term for the process of negotiating reimbursement rates and terms with providers?
What is contract negotiation.
When we vet a provider, name (2) metrics we access to see if we need them in the network.
Claim utilization, service in coverage area, network need, access issues.
If I want breakfast/lunch/snack onsite what app can I use to order ahead?
What is the Refuel App?
This is a standard metric mandated by CMS, often measured in miles or travel time, that a health plan must meet to ensure members have reasonable access to essential primary and specialty providers.
What is Geographic Access Standards/Time and Distance standards
Who is the newest member of our team?
Chloe
What is the name of the payment model that rewards providers for quality and efficiency rather than volume of services?
What is value-based care?
What is a “narrow network” designed to achieve?
Lower costs and higher quality through selective contracting.
If I need to see if a provider orientation was completed for a new participating provider/group where can I locate this information?
What is a SmartSheet?
This is the specific type of provider for which regulatory agencies often require the smallest time and distance standards.
What is a Primary Care Provider/PCP?
Who got married in September from our team?
Katrine Christenson