STMC Services
Managed Health Care Plans
What is Managed Care?
The term managed care can be used to refer to PPO products, HMO products,
EPO products, etc.
All physicians are individually credentialed through the various plans.
If a physician is not credentialed to see that particular plan's patients, no or reduced
benefits will be paid. Therefore, a first step regarding booking managed care patients
to a particular provider is the credentialing process.
A PPO product is one that will pay claims as long as the patient is seeing
an in-network provider.
An HMO product is one that has a “gatekeeper”. A gatekeeper
is a primary care physician that directs the patient for all other services. A visit to
a specialty physician or for specialized services must have a “referral” and/or
authorization. Some carriers allow this to be verbal referrals, others require that the
referral be obtained on paper and submitted to them. Failure to obtain referrals on
these patients will result in non-payment of claims.
Some HMO patients may self-refer to OB/Gyn through the Open Access program
for any OB/Gyn related diagnosis and well-woman exams. |
