Authorizations
A request, made by a provider, required by the plan, to review for medical necessity
Pre-Certification
This is the part of the team that is hired to handle the pharmacy benefits and pay pharmacy claims
PBM
This is the complete outline of the plan and is also known as the "constitution" of the plan
SPD
General Practice, Internal Medicine, Family Medicine and Pediatricians are examples of this
PCPs
If a member is diagnosed with a chronic or catastrophic condition, they may be referred to this nurse
PCG
UR nurses perform this to ensure the member is at the right level of care and to assist with discharge planning
Concurrent Review
The TPA is hired to perform what two functions for the self-insured health plans
Pay Claims + Administer the Plan
A fixed dollar amount the member must pay before the plan starts to pay a certain percentage
Deductible
An additional network that the plan contracts with for members who are temporarily outside of the primary network area
Wrap/Travel Network
A dollar or visit limit on a specific benefit
Plan Limitation
The term for medical records received from providers that are reviewed as part of the authorization process
Clinicals
These are the two main reasons an employer might choose to become self-insured
Plan Design + Savings
An employer funded account that is meant to help offset the costs of a high deductible
HRA
This is a common network style for hospital systems
Tiered Network
Approximately it takes how long for eligibility information to get to Quantum Health
Two Weeks
The question that should be asked before inputting provider information on an Inpatient Notification
Is the admitting physician a hospitalist?
This is the individual the employer hires to help build the team of experts for their self-insured plan
Broker/Benefit Consultant
A fixed dollar amount the member must pay before the plan starts to pay a certain percentage
Deductible
This type of specialist sees patient with diabetes
Endocrinologist
A fixed dollar amount a member must meet during the plan year before the plan starts to pay 100% for covered services done INN
Out of Pocket Maximum
We check this on all pre-certs, pre-ds, referrals, and IP notications
Network Status
The term for a critical piece of information that tells us who is covered, under which plan and for how long
Eligibilty
Employers may have a referral incentive for specialist office visits to encourage the member to do this
Start with their PCP
The PSR should quote from this section of SBS for sick office visits with an OBGYN
PCP Office Visit
The two ways do health plans calculate the allowed amount for out-of-network providers