“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
