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  1. The process by which a member, advocate, or provider requests a non-certification by a Carelon Peer Advisor be reconsidered.
  2. プロバイダーがネットワーク参加に関する不利な決定の再検討を要求するプロセス。

承認: Approval for a specific covered service to be delivered to a member. It represents agreement that the service is clinically necessary under the Carelon Medical Criteria.

アベイラビリティ エッセンシャル: A secure, one-stop, self-service claims portal and the preferred multi-payer portal of choice for submitting the following transactions to Carelon: claim submissions (direct data entry professional and facility claims) applications or EDI using the Availity EDI Gateway, eligibility and benefits, and claim status

バランス請求: The practice of charging full fees in excess of reimbursable amounts, then billing the patient for that portion of the bill not covered. This practice is not allowed by Carelon.


CareConnect: Web enabled Care Management software accessed by providers and Carelon staff. Replaced MHS system.

認証: The number of days, sessions or visits Carelon approves as medically necessary.



苦情(管理): A problem regarding a provider, institution, or MCO that any one other than a member presents either in written or oral form which is subject to resolution by Carelon.

苦情(メンバー): A problem regarding a provider or the coverage, operations or management policies of the HealthChoices program that a member or advocate (e.g. family member, guardian, or provider) presents to Carelon, either in written or oral form which is subject to resolution by the county/Carelon. Advocates, including providers acting as advocates, may present a complaint on behalf of a member, if they have received written permission from the member to do so.

同時レビュー: A review conducted by Carelon during a course of treatment to determine whether or not services should continue as prescribed or should be terminated, changed or altered.




資格認定: In order to be eligible for participation as a Carelon network provider, you must meet ケアロン プロバイダーの種類(個人、代理店、施設)および専門分野の資格基準。プロセスを完了するために必要なすべてのドキュメントと情報がによって受信されたときに、認証が開始されます ケアロン。アプリケーションは、必要なすべての必要な事務処理を指定します。

緊急事態: Critical events or outcomes involving patients seeking or receiving services under Carelon that may require further analysis. Such events include but are not limited to suicide, homicide, allegations of physical abuse/neglect, assaults, breach of confidentiality, leaving AMA, medications errors, adverse reaction to medications, property damage, and other. Critical incidents also include critical events or outcomes that occur during a patient’s transition to home or an alternative level of care.


拒否: A determination made by Carelon that reimbursement for a requested service will not be made. A denial can take the form of:

  1. リクエストは完全に不承認です。または
  2. the provision of the requested service(s) is approved, but for a lesser scope or duration than requested by the provider (an approval of a requested service which includes a requirement for a concurrent review by Carelon during the authorized period does not constitute a denial); or
  3. 要求されたサービスの提供は承認されませんが、代替サービスの提供は承認されます。


ヒューマンサービス部門公正聴聞会: For the purposes of this document, a hearing conducted by the Department of Human Services, Bureau of Hearings and Appeals in response to a grievance to the Department by a Carelon member.

診断(Dx): A classification for mental health and substance abuse related disorders, which may be defined on as many as five axes. Carelon uses the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association as its standard. The ICD-9CM is an international version, which includes both medical and mental health diagnoses.

登録解除: The termination of a practitioner, group practice or facility as a Carelon participating provider. Disenrollment can be initiated by Carelon or the participating provider, either with or without cause, in accordance with the contract terms.








1996年の医療保険の相互運用性と説明責任に関する法律(HIPAA):雇用関係が変更された場合、同等の健康保険の補償を受ける資格を即座に得ることを許可する連邦法。 HIPAAのタイトルII、サブタイトルFは、HHSに医療データの電子交換の標準の使用を義務付ける権限を与えます。これらの基準内で使用する必要のある医療および管理コードセットを指定するため。医療患者、医療提供者、支払者(または計画)、および雇用者(またはスポンサー)に国民識別システムの使用を要求すること。個人を特定できるヘルスケア情報のセキュリティとプライバシーを保護するために必要な対策の種類を指定します。ケネディ-カセバウム法案、カセバウム-ケネディ法案、K2、または公法104-191としても知られています。


HealthChoices Southwest(HC-SW)ゾーン:HealthChoicesの必須マネージドケアプログラムは、アレゲニー、アームストロング、ビーバー、バトラー、ファイエット、グリーン、インディアナ、ローレンス、ワシントン、ウェストモアランドの各郡で実施されています。





  1. 病気、状態、または障害の発症を防ぎます。
  2. 病気、状態、怪我、または障害の身体的、精神的、行動的、または発達的影響を軽減または改善する。
  3. 個人の機能的能力と同じ年齢の個人に適切な機能的能力の両方を考慮に入れて、個人が日常の活動を実行する際に最大の機能的能力を達成または維持するのを支援する。



非認証: In those cases in which the provider has not demonstrated medical necessity for proposed or continuing services at a particular level of care, a non-certification is rendered by Carelon. The non-certification constitutes a recommendation to the payer that services not be eligible for reimbursement under the benefit plan.

参加していないプロバイダーまたはネットワーク外のプロバイダー: A practitioner, group practice or facility that does not have a written provider agreement with Carelon and therefore is not considered participating in the network.


外来登録フォーム(ORF1): A Carelon form used to review outpatient mental health and/or substance abuse treatment for the certification of medically necessary services.

参加プロバイダー: A practitioner, group practice or facility whose credentials, including, but not limited to, degree, licensure, certifications and specialists, have been reviewed and found acceptable by Carelon to render services to Carelon members and be reimbursed at discounted rates.

ピアアドバイザー: A Carelon licensed psychiatrist, licensed psychologist, or master’s level licensed professional who provides peer reviews and clinical consultations on cases.

事前承認: A determination made by Carelon to approve or deny a provider’s request to provide a service or course of treatment of a specific duration and scope to a Member prior to the provider’s initiating provision of the requested service.

ProviderConnect: Web-based application developed and maintained by Carelon IT staff that allows providers to conduct transactions via a secured site including eligibility inquiries, claims inquiries, claims submission and care registration via the Internet.


再認証: The review process of determining if a provider continues to meet the criteria for inclusion as a Carelon participating provider. This process occurs every two years for individual practitioners and every three years for facilities.


サービス管理/マネージャー: Carelon function/staff with responsibility to authorize and coordinate the provision of in-plan services. Care management/manager is synonymous.

サイト訪問/治療記録のレビュー: As part of provider selection and quality monitoring, site visits and treatment record reviews will be conducted on selected providers as part of the credentialing and recredentialing process. Carelon has developed site visit and treatment record review criteria based on Carelon’s standards and the requirements of NCQA.