Glossary

Any compensation arrangement at any contracting level between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to Medicare or Medicaid enrollees in the MCO. MCOs must disclose physician incentive plans between the MCO itself and individual physicians and groups and, also, between groups or intermediate entities (e.g., certain IPAs, Physician-Hospital Organizations) and individual physicians and groups. See 42 C.F.R. § 422.208(a).

Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included.

See National Payer ID.

Your doctor's written plan saying what kind of services and care you need for your health problem.

An entity that sponsors a health plan. This can be an employer, a union, or some other entity.

An additional, mandatory supplemental, or optional supplemental benefit that allows theenrollee the option of receiving specified services outside of the plan's provider network.

A Medicare Managed Care Plan option that lets you use doctors and hospitals outside the plan for an additional cost.

A generic name for many work groups at WEDI and elsewhere.

The review of a claim after a determination and payment has been made to the provider or beneficiary.

A case developed after the PSC has substantiated an allegation of fraud.