PRV1_0119_ProviderManual-Commercial.pdf

A pcp may be either a family physician or provider

This preview shows page 15 out of 91 pages.

A PCP may be either a family physician or provider, general practitioner, internist, pediatrician, obstetrician, gynecologist, or other practitioner or nurse practitioner who has otherwise limited his/her practice of medicine to general practice or a specialist practitioner who has agreed to be designated as a primary care practitioner. Managed Care plans require that each enrollee be assigned to a primary care practitioner. Protocol: Description of a course of treatment or an established practice pattern. Provider: A person licensed, certified, or otherwise authorized by federal and/or state law to administer medical or mental health services in the ordinary course of business or practice of a profession. PacificSource further defines providers as physicians, dentists, nurses, physician assistants, podiatrists, chiropractors, acupuncturists, naturopaths, optometrists, mental health professionals, physical, speech, and occupational therapists, pharmacists, and other healthcare facilities or entities, including Individual Practice Associations or Medical Groups engaged in the delivery of healthcare services. Quality Assurance Program: A program and process that is carried out by PacificSource and contracted physicians and providers to monitor, maintain, and improve the quality of services provided to members as described in PacificSource Policies and Procedures. Quality Improvement: A continuous process that identifies problems in healthcare delivery, tests solutions to those problems, and monitors the solutions for improvement. Referral: The process by which the member’s primary care practitioner directs the member to seek and obtain covered services from other physicians and providers. Referral Authorization: The process of reviewing and authorizing referrals to specialists by primary care practitioners. Reinsurance: Insurance purchased by a carrier from another insurance company to protect itself against all or part of the losses that may be incurred by claims for its members (e.g., catastrophic care). Resource-Based Relative Value Scale (RBRVS): A financing mechanism that reimburses healthcare providers on a classification system. Risk: A possibility that revenues of the insurer will not sufficiently cover expenditures incurred in the delivery of contractual services. Risk Contract: An arrangement through which a healthcare provider agrees to provide a full range of medical services to a set population of patients for a prepaid sum of money or a predetermined budget. The physician or provider is responsible for managing the care of these patients, and risks losing money if total expenses exceed the predetermined amount of funds. Risk Pool: A category of services that are subject to some type of projected expense target. Typically, amounts over or under this target are shared with the medical group “at risk” for these services.
Image of page 15
You've reached the end of this preview.
  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

{[ snackBarMessage ]}

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern