Information regarding corporate managed updating
An adjustment can result from claims processing and/or billing errors (e.g., incorrect dispensing fee paid, incorrect pharmacy paid, incorrect administration fee billed, wrong carrier/group billed).An adjustment can also be processed against a general ledger account (e.g., bad debt or error).Health services provided without the patient being admitted. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading provided that the patient remains at the facility less than 24 hours. Average price paid to a pharmaceutical manufacturer by wholesalers for drugs distributed to retail pharmacies, net of prompt-pay (“cash”) discounts.AMP was a benchmark created by Congress in 1990 in calculating rebates owed Medicaid by pharmaceutical manufacturers.The problem of attracting members who are sicker than the general population, specifically, members who are sicker than was anticipated when developing the budget for medical costs.A tendency for utilization of health services in a population group to be higher than average or the tendency for a person who is in poor health to be enrolled in a health plan where he or she is below the average risk of the group.An expression used to describe all forms of health care delivery systems other than traditional feeforservice (FFS) indemnity health care.Just about all managed care organizations are called alternative delivery systems.
The leading national association of preferred provider organizations (PPOs) and affiliate organizations, and was established in 1983 to advance awareness of the benefits — greater access, choice and flexibility — that PPOs bring to American health care.
Approval usually is used to describe treatments or procedures that have been certified by utilization review.
Can also refer to the status of certain hospitals or doctors, as members of a plan.
This term is not to be confused with "usual and customary" or "approved" service.
The extent to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient's or member's needs.