Once the amount of Humana s coverage reaches the benefit maximum amount for the period, you are responsible for prescription drug costs until the next period begins. A monthly payment to providers based on membership rather than services provided. The payment covers contracted services and is paid in advance of care being provided. Case Management Coordination of services and resources for high-risk member in conjunction with member's physician. A medical system in which admission of other doctors is limited by the group.
Members can only use doctors in the group for their medical care.
The ongoing review of a patient s hospital care to determine whether or not the patient is still in need of acute care or whether he or she can be discharged soon. The control or reduction of inefficiencies in the consumption, allocation or production of health care services that contribute to higher than necessary costs. Credentialing A review process of potential medical providers to assess their standing and qualifications. A hospital payment methodology developed by Medicare that categorizes diagnoses into 468 classifications. The hospital is paid the amount assigned to the classification regardless of actual costs incurred.