1. What is preadmission certification, prenotification or precertification, and
what do they have to do with my coverage?
Preadmission certification, prenotification and precertification are terms
relating to medical cost-containment programs. They involve review of medical
necessity and whether alternate treatment methods are more appropriate. You may
have a penalty deducted from your medical benefits if you are required to
prenotify or precertify and fail to do so. Your claim also could be denied if
the service is not medically necessary. For more information, see
Utilization Management. Please consult your benefit booklet or call
Customer Service at the number on your ID card to determine if you are subject
to prenotification or precertification prior to receiving certain medical
services.
2. What is a third-party claims administrator?
A third-party claims administrator is a company that provides claim-payment
services to employer groups that are self-funded. The employer group designs
the benefit package and establishes the guidelines for processing of claims.
The third-party administrator issues the claim payments in accordance with
these guidelines. The employer group reimburses the claim payments, as well as
a fee for administration of the claims.
3. What is a provider?
A provider is a hospital, health-care facility, physician or other medical
professional that provides health-care services.
4. What is a PPO?
PPO stands for preferred provider organization. A PPO is a health-care system
that provides services to members at a discount or fixed fee. Preferred
providers are those who participate in the network and agree to the discounts
or fee schedule. Participating providers' charges for medical services usually
are lower than those of providers outside the network. The lower charges save
money for members (covered persons). Members also avoid filing claims since
providers are responsible for filing claims with USAble Administrators.
One of the PPOs available to USAble Administrators groups is the USAble® PPO.
USAble PPO has contracted with a group of providers statewide to form a
network. To receive discounts and to have claims filed by the network provider,
members must use those physicians and facilities that have contracted with the
PPO.
5. What is an HMO?
HMO stands for health maintenance organization, a health-care system that
assumes or shares both the financial and delivery risks associated with
providing comprehensive medical services to a voluntarily enrolled population
in a particular area, usually in return for a fixed, prepaid fee.
6. What is POS?
A point-of-service (POS) plan gives covered persons the option of going outside
a designated network. However, reimbursement usually is significantly reduced
for out-of-network services. For this reason, out-of-network utilization is
traditionally very low.
7. What is CMM?
Under comprehensive major medical (CMM or Major Medical), covered persons pay a
deductible, which is the first covered dollars of eligible charges incurred
during the contract year. Once the deductible is met, the member pays a
percentage of the covered dollars until the calendar-year, coinsurance maximum
is reached. CMM is a traditional fee-for-service plan that provides the same
level of benefits regardless of the medical provider chosen by the covered
person. One difference between CMM and a PPO is that CMM has no network.
