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Terms and Definitions
Referrals
Requirements
MIOD
100
Exceptions: Emergency services Urgently needed services Out-of-area dialysis Post-stabilization care services Member has a prior authorization for an out-of-network provider
What is Referrals
100
iBAAG displays. In this section, the plan will be listed as "Open Access" or "Gatekeeper."
What is Policy Data Section
100
Impacted states: Arkansas Kentucky New York Ohio Pennsylvania Tennessee Virginia Washington
What is States No Longer Enforcing Referrals in 2017
100
Transition of Care, Continuation of Care, Network Gap, Request for OON when INN available
What is Out of Network Provider Requests
200
Notification required for certain services, requested from the reviewing entity (the health plan or the delegated Primary Medical Group [PMG]). This notification can be initiated by the specialist or PCP prior to the service being rendered, and is to ensure the procedure the member is receiving is the proper treatment and medically necessary for the member's diagnosis.
What is Prior Notification
200
Assist you in advising if a referral is required or not
What is Referral Types
200
Notifies the providers about the change in the enforcement of the referral requirement.
What is A Letter
200
iBAAG or member's Evidence of Coverage (EOC) specifically states the requested benefit is not covered.
What is Non-Covered Benefit
300
Advance approval needed for certain drugs in order to cover the medications costs. The requirement for getting approval in advance helps guide appropriate use of these drugs. Members who do not get this approval might not have their drugs covered by the plan.
What is Prior Authorization
300
You access this in the Benefits tab of Account Summary
What is iBAAG
300
will not deny if the referral is not obtained
What is the claim
300
Where you find procedure codes for items such as DME greater than $1000
What is Prior Notification List
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
You do NOT need a referral to go to IN-Network specialist
What is Open Access
400
iBAAG Claims system
What is Updates are being processed
400
Internal Term
What is Gatekeeper
500
Entities associated with certain NICE platform accounts. They are in charge of delegating payment of claims, prior authorization requirements, and referral requirements (rather than the health plan).
What is PMG (Primary Medical Group)
500
For this particular PMG, a member can self-refer to an INN provider and the Health Plan is responsible for authorizations.
What is Direct Network Referral
500
This is effected by the no referral requirements
What is Gatekeeper Plans
500
Requests for the following benefits when above what the plan allows: Transportation trip or mileage Physical therapy visits Chiropractic or acupuncture
What is Benefit Exceeds Limit or Restriction