Delegation/Capitation
A formal process which gives a contracting medical group or provider the responsibility and authorization to perform certain functions.
What is Delegation?
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?
job aid used to assist with quoting benefits
What is Quoting Benefits Decision Tree?
Nice par status
What is Open?
reference for claim code types (job aid(s))
What is Claims Codes and ICES - Index?
A set payment amount Per Member Per Month (PMPM)
What is Capitation?
Notification required for certain services, requested from the reviewing entity (the health plan or the delegated Primary Medical Group [PMG]).
What is Prior Notification?
Cosmos has iBAGG, Nice has
What is Evidence of Coverage (EOC)?
called on Sept. 24, eff date will be
What is Oct.1st?
system used when claim not found
What is United Front End (UFE)?
UnitedHealthcare normally "delegates" two primary functions to its provider groups
What is Claims and Authorizations?
List that could be used to determine if an authorization is needed
What is Prior Notification List?
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?
states that have the same Retro change rules as COSMOS
What is AZ, NV, CO, TX, and OK?
job aid used to help with claim status and denial reasons
What is Nice Claim Codes?
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?
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?
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)?
errors, medical reviews, high dollar claims, and provider contract
What is factors that could impact claims turnaround times?