Facilities
These organizations consist of one or more physicians working together under common management, branding and/or aligned services.
What is a Provider Group?
This class of providers have specific training and experience within their chosen domain.
What is a Specialist?
Method of cost sharing where a health plan member pays a fixed amount of money directly to the provider when receiving the service.
What is a copay?
This process requires providers to obtain approval from the health plan before a prescribed treatment can be provided.
What is a Prior Authorization?
At minimum, members must be prompted to verbally state these two identifiers before Customer Service may proceed with the call.
What are Full Name and Date of Birth?
These health care facilities operate exclusively for the purpose of providing surgical services to members who will not require hospitalization.
What is an Ambulatory Surgery Center (ASC)?
This class of providers has a written agreement with a health plan to provide specific services at a specific rate of reimbursement.
What is a Contracted Provider?
The amount a member pays for covered health care services before the insurance plan begins to pay.
What is a deductible?
The process allows members, their representatives, or providers to ask a health plan to reconsider a decision on coverage or treatment.
What is an Appeal?
After identifying a caller of any type, Customer Service must ask for this number before "opening" the call in Facets.
What is a good telephone number?
These health care services or supplies are received by members, under doctor's orders, at their place of residence.
What are Home Health services?
This specialist provider focuses rendering care towards the unique needs of older adults, including chronic disease, mobility issues, cognitive impairments and medication management.
What is a geriatrician?
What is coinsurance?
The process by which a member or their representative may formally express dissatisfaction with actions or inactions of the health plan, or a provider contracted with the health plan.
What is a grievance?
This Facets application is used to record the details and categorization of all inbound member and provider inquiries.
What is the Customer Service application?
These facilities provide 24-hour a day nursing or restorative services to injured, disabled or sick persons.
What is a Skilled Nursing Facility (SNF)?
What is Primary Care Home?
The process by which one or more insurance companies determine which plan pays first when a member is covered by more than one plan.
What is Coordination of Benefits?
This process involves organizing patient care activities and sharing information with all providers, interested support persons and the member themselves, in order to manage chronic conditions and/or improve health outcomes.
What is care coordination?
What is consent?
These facilities are designed to support sick or injured persons who do not necessarily require emergency medical attention.
What is Urgent Care?
This class of provider has gone through a vetting process to verify background, education, licensure and competency prior to rendering care.
What is a Credentialed Provider?
This insurance process attempts to recover health plan costs incurred for member treatment, when the need for member treatment was caused by the actions of another person.
What is Third-Party Liability (TPL)?
This class of individual is authorized by a legal document to act on behalf of a health plan member.
What is an Authorized Representative?
This Facets "tab" contains the Effective Date which describes when a member first became a member of their current plan.
What is the Eligibility tab?