OPTUM®A program designed to help members manage personal problems. OPTUM works in coordination with Medica when a member needs assistance with legal issues, financial concerns, family problems, workplace stress or mental health/substance abuse issues.
Outcome Criteria Elements for evaluating end results in terms of health and satisfaction.
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PMAP See Prepaid Medical Assistance Program.
Participating Provider (a.k.a. Network Provider)
A health care provider who is appropriately licensed in the state or states where the provider renders health services and has entered into an agreement with Medica, has been accepted by Medica to provide health services to members, and whose status as participating provider has not been terminated by Medica.
Peer Review Organization (PRO) An entity established by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 to review quality of care and appropriateness of admissions, re-admissions and discharges for Medicare patients.
Performance Measurement A systematic process for assessing what an organization does and achieves across multiple dimensions.
Practice Profiling Assessment of patterns of health care service delivery and consumption over time. Units of analysis could include individual health care providers, groups of providers by specialty, departments, clinics and defined populations.
Pre-admission Screening (PAS) The assessment of enrollees for the purposes of preventing or delaying nursing facility placements and to offer cost-effective alternatives appropriate for the enrollees’ needs. They are conducted by the care system in conjunction with a county social worker upon enrollment into the MSHO program, and again as the condition of the enrollee change or annually, whichever happens first.
Preferred Provider Organization (PPO)
A contractual relationship among hospitals, physicians, insurers and third-party administrators by which the network of providers delivers health care services to employers and other purchasers based on a negotiated system of reimbursement using case management to review utilization.
Premium The monthly amount required to be paid by the employer on behalf of, or for, members.
Prepaid Medical Assistance Program (PMAP) Includes Medical Assistance (MA) and General Assistance Medical Care (GAMC) health plans.
Prescription Drug A drug approved by the Food and Drug Administration (FDA) for prescribed use and route of administration.
Primary Care The first-line health and medical care provided for the diagnosis and treatment of common ailments usually including most preventive, educational and health maintenance services. Primary care is most often provided by family practitioners, general internists, pediatricians and obstetrician/gynecologists who also serve as the primary physician responsible for the overall continuity of care. Primary care also involves guiding members to the most appropriate use of consultative and referral specialist services.
Primary Care Physician (PCP) A physician whose majority of practice is devoted to internal medicine, family/general practice or pediatrics. An obstetrician/gynecologist also may be considered a primary care physician, depending on the Medica product.
Provider A generic term used to encompass both participating and nonparticipating health care providers.
Provider Contingency Reserve (PCR) Amounts deducted and withheld from claims at the time of initial claim reimbursement to participating providers by Medica. The amount of PCR to be returned by Medica to participating providers is determined by the Medica board of directors. The individual clinic PCR return may be based on, but not limited to, plan financial performance and provider performance in the areas of quality, member satisfaction, access to care, and efficient and cost-effective delivery of care.
Provider Directory A listing of participating providers by specialty and location.
Provider Number The seven-digit number assigned to every Medica participating provider.
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Quality Assessment Complaint Tracking System (QAC)
An automated system designed to track members’ complaints and potential quality issues to identify patterns and trends in quality activities on a physician-specific and clinicspecific basis.
Quality Improvement Subcommittee A subcommittee of the Medica board of directors that oversees the Quality Improvement Program.
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Rate Cell The category attributed to an enrollee to determine the monthly capitation payment. A rate cell is assigned based on rate cell determinants, which may consist of all or a part of the following, consistent with Medicaid Management Information System (MMIS) requirements: county of residence, major program, eligibility type, sex, age, living arrangements, Medicare status and nursing home certifiability.
Recredentialing
The process whereby Medica periodically verifies the status of a participating provider and the provider’s continual satisfaction of credentialing requirements. Recredentialing considers additional information regarding the provider’s performance in Medica, including, but not limited to:
- Member complaints.
- Results of quality reviews.
- Utilization management information.
- Member satisfaction surveys.
- Medical record reviews.
- Results of site visits.
- Physician Performance Evaluation (PPE) results.
Referral Authorization process for a member to receive medically necessary health services from a provider outside of the member’s primary care clinic.
Referral Authorizaton Form A written or electronic document completed by a member’s care system that authorizes a member to receive certain health services.
Regional An operational term used to define activities outside the Twin Cities metropolitan area.
Restriction The exclusion or limiting, for a reasonable time, of the scope of health services for which a provider may receive payment from Medica.
Risk Contract An agreement between the Centers for Medicare & Medicaid Services (CMS) and an HMO or competitive medical plan requiring the HMO to furnish, at a minimum, all Medicarecovered services to Medicare-eligible members for an annually determined, fixed, monthly reimbursement rate from the government and a monthly premium paid by the member. The HMO is then liable for the cost services, regardless of their extent, expense or degree.
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