提供者手册

专业术语

访问服务: 会员在需要时能够获得服务的程度。

急性: 受疾病折磨，发病迅速，病程短而严重。

提倡: 经会员许可代表会员行事的家庭成员、监护人或提供者。

上诉:

1. The process by which a member, advocate, or provider requests a non-certification by a Carelon Peer Advisor be reconsidered.
2. 提供者请求重新考虑有关网络参与的不利决定的过程。

授权书: 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.

可用性要点： 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

余额计费: 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.

CAFS 协调员：儿童、青少年和家庭服务 (CAFS) 协调员负责审查 BHRS 请求、转介评估、促进和参与跨机构团队会议流程、审查 BHRS 数据包的完整性。

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

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

宣称：根据医疗保健服务的福利计划要求报销。

联邦: 指宾夕法尼亚州。

投诉（行政）: 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.

投诉（会员）: 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.

并发审查: 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.

签约供应商: 任何医院、专业护理机构、延伸护理机构、个人、组织或机构，其与保险公司签订了根据保险合同提供服务的合同安排。

护理协调：行为保健提供者之间以及行为保健提供者和身体保健提供者之间协调护理的过程，目的是提高成员保健的整体质量。

涵盖的服务：福利计划范围内的心理健康和药物滥用服务。

认证: In order to be eligible for participation as a Carelon network provider, you must meet Carelon 您的提供者类型（个人、机构、设施）和学科的认证标准。当完成该过程所需的所有文件和信息已由以下人员收到时，认证开始 Carelon.该应用程序指定所需的所有必要文书工作。

紧急事件: 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.

文化能力：网络以符合其文化、宗教、种族和语言背景的方式满足成员行为健康需求的能力。

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

1. 该请求被完全拒绝；或者
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. 拒绝提供所请求的服务，但批准提供替代服务。

部门: 宾夕法尼亚州公共服务部

人类服务部公平听证会: 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.

诊断 (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.

退学: 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.

出院计划: 评估成员的心理健康或药物滥用服务需求，或两者兼而有之，以便在从一个护理级别转为另一级别护理后安排适当的护理。

国土安全部: 人类服务部

双重诊断：用于描述同时患有精神疾病和物质使用障碍诊断、发育障碍和/或医学诊断的个人。

合格: 确定个人满足接受计划规定的医疗保健福利的要求。

资格验证系统 (EVS)：宾夕法尼亚联邦的自动化系统可供供应商在线验证资格。

福利说明 (EOB)：邮寄给提供者的声明，解释为什么索赔被支付或没有被支付。

申诉：申诉是会员、会员代表或提供者（在会员书面同意的情况下）提出的重新考虑有关承保服务的医疗必要性和适当性的决定的请求。

1996 年健康保险携带和责任法案 (HIPAA)：一项联邦法律，允许人们在改变雇佣关系时立即有资格获得类似的健康保险。 HIPAA 的标题 II，副标题 F 授权 HHS 授权使用标准进行医疗保健数据的电子交换；指定在这些标准中应使用哪些医疗和行政代码集；要求对医疗保健患者、提供者、付款人（或计划）和雇主（或赞助商）使用国家识别系统；并指定保护个人可识别医疗保健信息的安全和隐私所需的措施类型。也称为肯尼迪-卡斯鲍姆法案、卡斯鲍姆-肯尼迪法案、K2 或公法 104-191。

健康选择：宾夕法尼亚州 1915(b) 豁免计划的名称，旨在为医疗援助 (MA) 成员提供强制性管理式医疗保健。

HealthChoices 西南 (HC-SW) 区：在阿勒格尼、阿姆斯特朗、海狸、巴特勒、费耶特、格林、印第安纳州、劳伦斯、华盛顿和威斯特摩兰县实施的 HealthChoices 强制性管理式医疗计划。

住院服务：在要求会员在设施中过夜的环境中提供的针对行为健康状况的医疗服务。

停留时间: 会员处于特定护理级别的天数。

护理水平：为达到特定护理阶段的治疗目标所需的专业护理强度。

医疗必要性或医疗必要性: 建立一项服务或福利的临床决定，该服务或福利将或合理预期：

1. 预防疾病、状况或残疾的发作；
2. 减少或改善疾病、状况、伤害或残疾对身体、心理、行为或发育的影响；
3. 协助个人在进行日常活动时达到或保持最大的功能能力，同时考虑个人的功能能力和适合同龄人的功能能力。

成员: 福利计划涵盖的任何个人。

负余额：为提供的服务多付的美元金额。

非认证: 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.

非参与提供者或网络外提供者: 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.

门诊服务：在门诊护理环境中提供的心理健康和药物滥用服务，例如心理健康或药物滥用诊所、医院门诊部、社区健康中心或提供者办公室。门诊服务包括但不限于以下服务：个人、家庭、夫妻和团体治疗；药物管理、诊断评估、病例管理和基于家庭的服务。

门诊登记表 (ORF1): A Carelon form used to review outpatient mental health and/or substance abuse treatment for the certification of medically necessary services.

参与提供商: 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.

同行顾问: A Carelon licensed psychiatrist, licensed psychologist, or master’s level licensed professional who provides peer reviews and clinical consultations on cases.

预授权: 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.

质量保证/改进: 一个结构化的系统，用于持续评估和改进向会员提供的整体服务质量。

重新认证: 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.

回顾性审查: 治疗完成后通过病例审查确定护理必要性的过程。

服务管理/经理: Carelon function/staff with responsibility to authorize and coordinate the provision of in-plan services. Care management/manager is synonymous.

现场访问/治疗记录审查: 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.

Utilization Management: The process of evaluating the necessity, appropriateness, and efficiency of behavioral health care services against established guidelines and criteria.