Living wills for Medicare beneficiaries. The Health Care Financing Administration requires that these be distributed to all Medicare members when they are admitted to hospitals, even if it is a readmission.
When you see a "balance forward" on your billing statement, it means that some previous charges, adjustment and/or payments have aged at least one billing cycle (at least four to six weeks). Please refer to your previous statement for details about these previous charges, adjustments and/or payments.
The specific health care services which a health plan agrees to reimburse for its members. Note that a health plan may require its members to meet certain conditions (ex. prior authorization, use of specific preferred providers) in order to be eligible for reimbursement.
A payment system in which fees are paid per person or "per capita" and a primary care provider is financially responsible for coordinating patient care within the fees or capitated rate for all his/her patients. Capitation means a provider is given a maximum amount of money per person no matter how many or how few services are provided.
The patient's part of the bill paid at the time of service. Co-payments are usually flat fees for a particular service (e.g. $15 per doctor visit or $20 per prescription).
The review process of health care providers to examine the license, certification, evidence of malpractice insurance and history, and includes information given by the provider as well as by other organizations and individuals.
The process of a physician managing a patient's disease (such as asthma or diabetes) on a long-term, continuing basis, rather than treating it as a single episode. Disease management is intended to improve patient care.
The specific list of drugs that a health plan will pay for as part of the benefit package. These drugs are available through the plan or member pharmacies and are frequently reviewed and revised.
Forms sent to patients that explain which procedures and services were given, how much they cost, how much is covered by insurance and how much the patient must pay.
The person who controls a patient's access to health care services, whether as a case manager or a primary care provider who must approve all referrals and use of health care services. This term is typically used in managed care systems.
A type of Medicare Health Plan that is available in most areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in the Original Medicare Plan
Organization that offers reimbursement for its members' health care services. It can be an HMO, a preferred provider organization, a commercial insurance carrier or a company that self-insures.
Health care services that require overnight care at a hospital or other health care facility, or require a physician's oversight for at least 24 hours.
A legal document people use to state how they want to be treated if they cannot speak for themselves or cannot communicate about what they want to happen to them.
Services required to prevent harm to the patient or an adverse effect on the patient's quality of life. The term is usually used to determine whether or not a procedure or service is covered by insurance.
A provider who is not part of a specific health plan. Since these providers do not have contracts with a health plan, and are not credentialed by the health plan, patients using these providers must pay out-of-pocket for the care themselves.
Nurses, physician's assistants and other non-physicians who can deliver medical care under the sponsorship of a practicing physician. Also sometimes known as "mid-level provider".
Places which are out of the health plan's service area. Out-of-area can be both geographic as well as a reference to services outside a specific group of providers.
A provider who is under contract with the health plan to provide services. This includes not only physicians and hospitals, but also optometrists, pharmacies and other designated individuals and services.
An agency, insurer or health plan that pays for health care services and is responsible for the costs of those services. Payers include the government (e.g. Medicare), commercial insurance and employers' self-insured plans.
Health professionals, such as nurse practitioners or health educators, who work with patients in order to make the patient's time with the physician more efficient and productive.
A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
Health care services that stress regular testing, screening for diseases, such as mammograms or blood tests, or having childhood immunizations and other health services that detect diseases early on or prevent them from occurring.
Health care services that focus on preventive care and is different from health care services provided by specialists. General practice, family medicine, internal medicine and pediatrics are considered to be primary care.
The physician who is responsible for coordinating all care for an individual patient, from providing direct health care services to referring the patient to specialists and hospital care. Managed care plans such as HMOs rely on PCPs to coordinate subscribers' care.
Procedures, tests, services, or medications which must be approved in advance by the doctor, utilization management and/or the insurer in order to be eligible for payment from the health plan or insurer.
A type of Medicare Health Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn't cover.
People and/or institutions that give health care services; it includes social workers, physicians, hospitals, nurses, or any other formal health care giver.
May be either an informal suggestion from one provider for the patient to see another provider, or a formal process within managed care plans by which the primary care physician refers the patient to specialists, hospitals or other services.
A setting for patients with skilled care needs who no longer require hospital care, but need 24-hour nursing care and other defined health care services.
The process health plans and insurers use to ensure a patient's medical needs are provided in the most appropriate and cost-effective setting. Our Clinic's utilization management services are conducted by the Managed Care Referrals Department.
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Sansum Clinic is here …for your good healthA 501(c)(3) California nonprofit public benefit corporation.
