Delegation/Capitation
Referrals/Authorizations
Quoting Benefits
Providers
Claims
100

A formal process which gives a contracting medical group or provider the responsibility and authorization to perform certain functions.

What is Delegation?

100

A recommendation by a medical professional (usually the PCP) for the member to receive additional care from another source (i.e., a specialist).

What is Referral?

100

job aid used to assist with quoting benefits

What is Quoting Benefits Decision Tree?

100

Nice par status

What is Open?

100

reference for claim code types (job aid(s))

What is Claims Codes and ICES - Index?

200

A set payment amount Per Member Per Month (PMPM)

What is Capitation?

200

Notification required for certain services, requested from the reviewing entity (the health plan or the delegated Primary Medical Group [PMG]).

What is Prior Notification?

200

Cosmos has iBAGG, Nice has

What is Evidence of Coverage (EOC)?

200

called on Sept. 24, eff date will be

What is Nov.1st?

200

To get all the information about a claim's status, use the (???) in the Summary section.

What is Claims Note Box?

300

UnitedHealthcare normally "delegates" two primary functions to its provider groups

What is Claims and Authorizations?

300

List that could be used to determine if an authorization is needed

What is Prior Notification List?

300

 when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention...

What is Medical Emergency?

300

states that have the same Retro change rules as COSMOS

What is  AZ, NV, CO, TX, and OK?

300

job aid used to help with claim status and denial reasons

What is Nice Claim Codes?

400

a type of contract in which the PMG assumes financial risk for physician services, and UnitedHealthcare assumes financial risk for hospital services

What is Shared Risk?

400

A plan that requires the member to coordinate with their PCP to obtain a referral PRIOR to seeing a specialist. Failure to comply with this requirement may result in non-payment of services.

What is Gatekeeper Plan?

400

Additional way to quote benefits for Nice member's

400

an MA plan that limits plan members to a subset of contracted providers located within a plan's service area.

What is Provider Specific Plan (PSP)?

400

errors, medical reviews, high dollar claims, and provider contract

What is factors that could impact claims turnaround times?

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