Credentialing Process of reviewing potential provider applications to ensure all necessary criteria are met. E Eligibility Verification Process by which participating providers confirm patient group enrollment and eligibility for the treatment of covered services, as defined in the plan design. M Managed Care System by which both the finance and delivery of health care are pro-actively managed to access cost, network use, and quality. A managed care organization which contracts with a selected group of health care providers to deliver medical care to a specific group of participating patients. The negotiated fees applied by the plan administrator or insurance carrier.
Reimbursement is based on a fee schedule and the respective plan benefits.