The type of health plan is HMO Health Plan because it is one that offers extensive healthcare services range through a network of providers who have agreed in supplying services to members. After discharge, the patient gets allowed to receive home treatment.
The type of third-party plan used here is the private health insurance program where the patient can get attended to while still at home under preferred provider networks and managed programs.
Delegate your assignment to our experts and they will do the rest.
To avoid one's health care claims being denied, one should make sure the medical service, treatment or procedure they seek get authorized and recommended by the primary care doctor or physician they had been referred to for care by the clinic staff or doctor. When filing claims, as long as one understands their benefits and their demands are in the limits of their coverage, then they should have no problem with the application process. Moreover, one must go through the benefits and coverage that gets specified in their policy or contact their insurance company in determining whether their services get covered. To file a claim in the case above, filling a healthcare claim on insurance is not difficult. However, the process of the allegation happens slowly. One should contact an independent agent in a choice that gets trusted in the network and who specializes in health care coverage (Berwick, 2008).
The various procedures for obtaining a referral include assessment, a GP’s mental Health care plan, differentiated services, what a psychologist does, what differentiates the challenge of the family psychology clinic and the common questions (PROCEDURES, 2013).
The admission department has to obtain all the required information before a patient gets admitted. The steps start with registration of the patient’s information, utilization review, verification of insurance, patient’s chart preparation, room/bed assignment, admission summary admission, and hospital’s update of the census.
Mr. Moore requires a referral because he is under Hospital Outpatient Clinic.
To complete the precertification process, the patient should make sure that the service gets covered by the plan and that the patient is a member of the program. The member ID card should get seen for the number of the call for participation (Boland, 2014).
Patient-centered medical home service refers to the delivery care model where patient treatment gets coordinated through the patient’s primary care physician in ensuring they get the necessary attention where and when they need it, in a way they can understand.
Fraud refers to an intentional deception and facts misinterpretation resulting in unauthorized payment or benefit. For instance, falsifying medical records or claims, and falsifying eligibility. On the other hand, abuses are inappropriate and improper actions outside standards that are acceptable of professional conduct and medically unnecessary. Examples of abuse include improper billing practices and failing to maintain adequate financial and medical records.
R eferences
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health Affairs , 27 (3), 759-769.
Boland, G. W., Duszak, R., & Dreyer, K. (2014). Appropriateness, scheduling, and patient
negotiating special education, and confidentiality. Providing Mental Health Servies to Youth Where They Are: School and Community Based Approaches , 75.
preparation. J Am Coll Radiol , 11 , 225-226.
PROCEOURES, R. (2013). Practical issues in school mental health: Referral procedures,
