‘s Utilization Management?
Utilization Management is the process of reviewing the appropriateness
and the quality of care provided to patients. UM may occur before (pre-certification),
during (concurrent) or after (retrospective) medical services are rendered.
For example, your health plan may require you to seek prior authorization
from your utilization management company before admitting to a hospital
for non- emergency care reduce unnecessary hospitalizations, treatment
and costs. This would be an example of pre-certification. Your medical
care provider and a medical professional at the UM company will discuss
what is the best course of treatment for you before care is delivered.
UM can reduce unnecessary hospitalizations, treatment and costs.
What is a Deductible?
A deductible is the amount of money you or your dependents must pay toward
a health claim before your organization's health plan makes any payments
for health care services rendered. For example, a plan participant with
a $100 deductible would be required to pay the first $100, in total, of
any claims during a plan year.
What is Coinsurance?
Coinsurance is a provision in your health plan that describes the percentage
of a medical bill that you must pay and that which the health plan must
What is Out-Of-Pocket Maximum?
The maximum amount (deductible and coinsurance) that an insured will have
to pay for covered expenses under a plan. Once the out of pocket maximum
is reached the plan will cover eligible expenses at 100%.
What is an Explanation of Benefits (EOB)?
An EOB is a description your insurance carrier sends to you explaining
the health care benefits that you received and the services for which
your health care provider has requested payment
What is a Pre-Existing Condition?
A pre-existing condition is a physical or mental condition that existed
prior to being covered on a health benefit plan. Some insurance policies
and health plans exclude coverage for pre-existing conditions. For example,
your health plan may not pay for treatment related to a pre-existing condition
for one year. You should check with your insurance carrier to learn how
your organization's health plan treats pre-existing conditions.
What is a Preferred Provider Organization (PPO)?
A PPO is a group of hospitals and physicians that contract on a fee-for-service
basis with insurance companies to provide comprehensive medical service.
If you have a PPO, your out-of-pocket costs may be lower in a PPO than
in a non-PPO plan.
What is an Archer Medical Savings Account?
The Archer MSA program enables certain persons (self-employed individuals
and employees of small employers) with high-deductible health plans to
contribute on a tax-free basis to medical expense reimbursement accounts.
For details on this type of account, try this IRS link: http://www.irs.gov/pub/irs-pdf/p969.pdf
Where can I go if I have COBRA questions?
Where can I go if I have HIPAA questions?
here for HIPAA FAQs
Frequently Asked Questions