A Physician Who Has a Contractual Agreement with a Third-Party Payor. (Use an Acronym)

WAN refers to a “wide area network” in which several different computer systems in a network are connected to each other in order to be able to communicate with each other. The agency is connected to the Santa Barbara County WAN. An agreement that you sign that gives you permission to receive medical services or treatment from doctors or hospitals. HMO (Health Maintenance Organization). A company that provides or arranges the provision of comprehensive medical services for a fixed and prepaid premium. The term was first used officially when the federal HMO law was passed in the early 1970s. More than 40 million people are now enrolled in HMOs nationwide. HMOs use a managed care approach to service delivery. ICD-10-CM is the official system for assigning codes to diagnoses and procedures related to hospital use in the United States.

CRVS (California Relative Value Scale). A list of procedural codes and their values; for billing and the assignment of reimbursement values to services provided by physicians. VISIT TO THE OFFICE In general, refers to medical services provided in an outpatient setting. A hospital or doctor who provides medical care to the patient. GENERIC The chemical equivalent of a brand name drug manufactured by another company because the original patent on the brand name has expired. The generic version is generally more cost-effective and, as a result, many managed care programs promote or require the use of generics when they are available and when the prescribing physician authorizes substitution. The federal agency that manages the Medicare program. In addition, CMS works with states to implement Medicaid programs.

As a rule, the price charged by the supplier. In particular, a charge for a given service is considered to be `usual and customary` if it falls within the range of prices charged for the same service by other providers in the same geographical area. Typically, an insured person pays a premium each month for private insurance coverage and, in some cases, for public insurance programs. Once the insured receives health care and the health care provider has submitted a claim to the third-party payer, the third-party payer sends the payment to the provider of covered unpaid procedural fees on behalf of the insured. IQIP (Internal Quality Improvement Project). A project proposed by the agency and approved by DHS that meets established guidelines for interventions with a member population that can improve health status. These projects can be clinical in nature and not clinical in nature. Helps pay for medical services, outpatient care, and other medical services that are not paid for by Medicare Part A. A third-party organization in the billing process and separate from the health care provider and the insurance payer.

Clearing houses review, amend and format claims before they are sent to insurance payers. This process is sometimes referred to as “washing”. ILRC (Independent Living Resource Center) A local non-profit organization that provides orientation and support services to people with disabilities. In most cases, when a person receives a service, they pay the service provider directly. However, when it comes to health care, the cost of direct payment is often too high for one person to pay alone. It can count on a third-party payer to cover its costs. In most cases, this is an insurance company. Candice goes for a colonoscopy.

The procedure is expensive, but Candice has paid a monthly premium to her insurer and they act as third-party payers to cover the cost of colonoscopy. The legal agreement between a health care plan and you. This contract establishes the full range of services available to you through your health insurance plan. A service contract is sometimes referred to as a cover certificate or proof of coverage. DRUG LIST A LIST OF DRUGS THAT ARE APPROVED FOR COVERAGE AND THAT CAN BE DISPENSED WITHOUT PRIOR APPROVAL. CenCal Health uses the state Medi-Cal drug formulary as the basis and has changed it significantly over the years. All drugs that are not listed on the CenCal Health Formulary require prior approval to be reimbursable. A highly deductible health care plan (HDHP) with a Health Savings Account (HSA) provides medical care and a tax-free way to save for future medical expenses. A high-deductible health care plan usually does not cover health care costs until the deductible is reached, which means that you are responsible for the costs of health care out of your own pocket until you reach your deductible. Once the deductible is reached, eligible health care expenses will be covered by the plan. PPO (Preferred Provider Organization). A program in which contracts are negotiated with selected suppliers at discounted prices; OPP members who purchase their services from their preferred providers typically pay little or no fee for this, but pay much more if they see a non-contractual provider.

POPs typically charge higher premiums than HMOs. In the case of individual contracts (for individuals and their families), the exclusion of pre-existing conditions is broader than in the markets of small and large employers and also includes a condition for which a reasonable person would have requested treatment, even if the treatment had not been recommended or received. In addition, pregnancy can be considered a pre-existing condition. .