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The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she
cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon
becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon
will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan
determine how well she met Canyon's standards. The report included cumulative performance
data for Dr. Enberg and encompassed all measurable aspects of her performance. This report
included such information as the number of hospital admissions Dr. Enberg had and the number of
referrals she made outside of Canyon's provider network during a specified period. Canyon also
used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's
performance.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan
member for covered services is known as:
In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:
One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of __ __ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.
With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to
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