Medical billing basic terms, definitions - capitation fee, covered services, dependent, emergency Medical condition

“Capitation Fee” means the monthly payment made by CarePlus to the Provider for each Enrollee assigned to Provider. The amount of the Capitation Fee is set forth in the PCP Agreement.

“Clean Claim” is a claim that has no defect or impropriety, including lack of required

substantiating documentation for non-contracted providers and suppliers, or particular circumstances requiring special treatment that prevents timely payment from being made on the claim. A claim is “clean” even if CarePlus refers it to a medical specialist for examination. If additional documentation in the medical record involves a source outside CarePlus, the claim will not be considered “clean”.

“Copayment” means the amount required to be paid by Member to Provider as additional payments

for Covered Services as are Medically Necessary and shall include fixed payments to be paid as well as percentage amounts based on the cost of a service (i.e. “co-insurance”). Copayments will vary in amount for Members, depending on benefit structure

“Covered Services” means those medical and hospital services that are expressly covered under any Subscriber Certificate and are medically necessary as determined by CarePlus’ Medical Director

“Covering Provider” means a physician who will continue to render Covered Services to Members during those times when Provider cannot provide these services as set forth in this Agreement, but is doing so under the same terms of this Agreement

“Dependent” means a family member of a Subscriber who are eligible for coverage under the Subscriber Certificate and who have been enrolled in CarePlus

“Emergency Medical Condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman,

the health of the woman or her unborn child;

(2) Serious impairment to bodily functions; or

(3) Serious dysfunction of any bodily organ or part.

“Emergency Services” means covered inpatient and outpatient services that are:

(1) Furnished by a provider qualified to furnish emergency services; and

(2) Needed to evaluate or stabilize an emergency medical condition.

  

“Enrollee” means a Subscriber or Dependent who is enrolled in CarePlus. An enrollee is also referred to as a “Member”. “Medicare Enrollee” means an Enrollee who is entitled to medical and hospital benefits under Title XVIII of the Social Security Act, as amended