Delegation/Capitation
What is a set payment amount for services rendered?
once in AARPMedicarePlans.com, used to give detailed benefits
What is Evidence of Coverage (EOC)?
are currently required for all plans on the NICE claims system
What are referrals?
counties in Arizona have PSPs
What is Maricopa and Pinal?
If the claim is not found in account summary, you would then need to
What is verify delegation?
The terms (??) and (??) go hand in hand
What is Financial Risk and Capitation?
amount calculations are based on the Contracted fee or Medicare approved amounts for each service, and not total claim amount.
What is Coinsurance?
managed by the reviewing entity (plan or PMG)
What is authorization?
change requires specific information to be documented in the Tier 1 comments
What is Retro PCP Change?
To get all the information about a claim's status, use the (?????) in the Summary section
What is Claims Note Box?
There are primarily three capitation arrangements
What is global capitation, split (partial) capitation and share capitation?
Benefit Period
What is used to measure the member's use of hospital and SNF services?
required for gatekeeper plans, except in emergencies
What is facility, medical group, and physician
received Denial code DK
What is Not Medically Necessary?
Two places where you can verify delegation
What is summary and plan tab?
The Benefits Inquiries - Index job aid includes a (???) section that includes helpful information and links to related resources
What is frequently asked questions?
list where you can verify if an authorization is needed
What is Prior Notification List?
PSPs consist of what 2 states
What is Arizona and California?
received Claims Code Pendinging 1P
What is Potential Duplicate?