Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006TERMCall RecordCall UserCanCandidate(s)Capability Maturity ModelCapitationCapitation Carve OutCapitation PaymentCapitation Payment FundCapsCaptivaCare ManagementCarrierCase Management RecordCase ManagerCase MixCase NumberCase ReferrerDEFINITIONresponsible for assigning issues to other users. The call manager typicallydocuments each action taken to resolve an issueAn instance of a call from a member, provider, or employerAny person who answers the telephone or who resolves issues when members,providers, or employers call into the organizationUsed to express non-mandatory provisions; words denote the permissiveMembers who are going through a Case Management Services review process todetermine whether they are eligible for case management services. The CaseManager creates a candidate record for those candidates whose collectedinformation supports acceptance into the Case Management programAn information technology system development methodology developed andpromoted by Carnegie Mellon University to measure and certify the methods andcontrols used by a company or agency in the development of IT systemsA system of payment, used in healthcare by managed care plans, for each patientserved, rather than by service performed. Amounts are determined by assessing apayment per covered life or per member for a given time period. Providers are notreimbursed for services that exceed the allotted amountServices that are excluded from a global capitation agreementPayment to a provider for capitated servicesA specific payment fund reserved for capitation paymentsLimits on services available to a client enrolled in a benefit plan, such as thenumber of dentures a recipient may receiveThird party vendor, source for Base for reference and pricing informationincluding diagnoses, service codes, modifiers, revenue codes, other code sets, andquarterly pricing changesProcess that focuses on identifying client’s needs, registering those clients intoprograms, and maintaining the plan of care or case.The entity/health plan that underwrites or administers programs and is ultimatelyresponsible for claims incurred by membersIn Health PAS, the Carrier portal represents the highest level of organization andenables the State to manage various lines of business. It is also the highest level ofsummarization for reporting purposes. Health PAS supports three distinct types ofcarriers: Health Plan (the health insurance organization), COB Carriers (otherhealth insurance organizations through which members have medical insurance),and TPL (third-party-liability or auto) carriersA record created when a case management services candidate has beendetermined to benefit from a specific case management plan and has beenapproved for case management servicesThe single point of contact for providers and those members who are supportedwith case management services; trained to know medical and non-medicalresources to assist patientsThe type or mixture of treatment provided to an enrollee by an Intermediate CareFacility (ICF) or nursing homes.Number assigned to a provider application in Health PAS-OnLine; used if theapplication is incomplete and the provider returns to complete the application at alater time; also used to access the provider enrollment data for edits or updatesIndividuals who search for and create candidate records for Case Management;14.14.2-5