Tip: Create a managed care plan matrix
Patient Access Weekly Advisor, July 16, 2008
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It is useful to have a contracted insurance matrix that access staff members can use as a reference guide to identify which plans have managed care requirements. The matrix should include the following data elements:
· A complete list of all contracted insurance healthcare plans.
· Types of plans included in the contract (e.g. HMO, PPO, POS). Listing the included plan types is crucial. Do not assume that the contract includes all plan types.
· All contact numbers.
· A list of services requiring pre-certification by plan type. Often, insurance plans have different pre-certification requirements by plan type (i.e., HMO may require pre-certification, but PPO plans may not have the same requirement).
· Services that require referral or notification requirements.
· Reimbursement penalties if authorization is not obtained.
Note: This tip was featured in The Patient Access Director’s Handbook. To learn more about this book, click here.
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