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Medicaid 101
Government Programs 101
Provider Types
Ancillary Services
Terms and Definitions
100
A comprehensive approach to the provision of health care which combines clinical preventive, restorative, and emergency services and administrative procedures within an integrated, coordinated system to provide timely access to primary care and other medically necessary health care services in a cost effective manner.
What is a managed care organization?
100
Identify what is missing....MLTSS, MEDICARE, DSNP
What is Medicaid?
100
This doctor treats the glands that produce and secrete hormones that control and regulate nearly all of the body's functions.
What is an Endocrinologist?
100
Blood Work
What is Laboratory/Pathology?
100
When the provider is billing the member for the difference between the amount(s) charges, and the payment(s) made by Horizon NJ Health.
What is Balance Billing?
200
Runs from 10/1-11/15 each year.
What is open enrollment period?
200
This team handles, Prior Authorization (inpatient, outpatient, home, special services, and DME)
What is Utilization Management or UM?
200
Conduct aesthetic and cash-pay elective procedures such as botox, lasering.
What is a Dermatologist?
200
Wheel Chair
What is Durable Medical Equipment?
200
When a member is covered by more then one insurance policy.
What is Coordination of Benefits (COB)?
300
Administers State and Federal Medicaid Program and NJ FamilyCare Program and Contracts with Medicaid HMOs to provide services.
What is the Department of Human Services (DHS)?
300
This team uses the approach which may include the Primary Care Provider (PCP), specialists, home health agency, discharge planners, therapists, social workers, nurses, behavioral health, pharmacy, medical directors to meet the health care and community service needs of the member on a short or long-term basis.
What is Care/Case and Disease Management?
300
Treat patients who have swine flu, bird flu, HIV/AIDS, etc.
What is an Infectious Disease Doctor?
300
MRI
What is Radiology?
300
Health care program which provides an integrated set of services designed to provide comfort, pain relief and supportive care for terminally ill or terminally injured people
What is Hospice?
400
- Loss of financial or medical eligibility - Moves out of State - Member becomes institutionalized - Non-payment of premiums (NJ FamilyCare only)
What are the reasons for Medicaid Involuntary Disenrollment ?
400
Hospitals, Physician, Ancillary and Medicaid Long Term Services?and Support Providers all contracted through this team.
What is Provider Contracting & Strategy (PC&S)?
400
Treat kidney disease, and prescribe dialysis for those experiencing kidney failure.
What is a Nephrologist?
400
Prosthetic leg
What is Orthotics and Prosthetics?
400
Is the exclusive lab services provider for Horizon NJ Health.
What is LabCorp?
500
Proof of Medicaid Insurance provided by the State of NJ.
What is the Medicaid HBID (Health Benefits ID) Card?
500
Chief Medical Officer for Govermnent Programs.
Who is Paul G. Alexander, MD, MPH ?
500
These healthcare professionals serve a wide range of healthcare services provided to support the work of a primary physician.
What is an Ancillary Provider?
500
Nursing Services in the Home
What is home health nursing?
500
A request for a review and authorization for services prior to rendering to determine eligibility under the member’s contract.
What is pre-certification or authorization?