Clinical Programs and Services
Term for a provider who has not contracted with Elevance?
What is - An OON (Out of Network) Provider
Planning that begins before admission, or on the day of admission
What is - Discharge Planning
Individuals who are legally allowed to make medical decisions and/or receive PHI information from Elevance Health
What are - personal representatives/authorized persons
Term that is the maximum paid out by the plan for any service?
What is: The Maximum Allowed Amount
The collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to promote quality care and cost effective outcomes
What is Case Management
5 different types of ways to identify HIPAA with a member
What is - Name, DOB, Address, Phone Number, Subscriber ID
Amount paid out by the member before the plan pays anything
What is - The Deductible
This is the movement of patients between health care providers and settings as conditions and care needs change during the course of chronic or acute illness
What is transition of care
This is the process of obtaining information from the requestor in order to speak to them about anything on the account/plan
What is verification, authentication, or HIPAA verify
Percent (%) a member pays as a cost sharing portion of their insurance plan
What is - CoInsurance
The process of evaluating a health care service or procedure for medical necessity of care, appropriateness and efficiency of care, and the member’s coverage under plan guidelines
What is Utilization Management
This information can only be discussed with those individuals that have been fully authenticated
What is - Protected Health Information or PHI
What is - CoPayment
Identification, assessment, and registration of members for specialty programs included as part of a member's health plan coverage
What is - Referral Management
Term used when PHI is obtained or distributed illegally or by accident
What is - breach