Page 31 - PPO_Member_Kit

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Doctor Data – About Our Credentialing Process
We want to make sure you have quality experiences and quality doctors. We make sure all our
doctors, PCPs and specialists go through a credentialing process. This process ensures that our
education and training standards are met.
Credentialing helps you get the most from your health plan. How? By providing you with background
information so you feel confident that you’re getting great care. You want to know that your doctor is
board certified. We give that information to you. When it’s time for you to choose your doctor, you
may want this information to help you in making an educated choice. Knowing that your doctor has
completed all necessary requirements will give you peace of mind. We look at state licenses to make
sure that doctors meet our guidelines and those from the state. This information is monitored, and we
re-credential our doctors at least every three years.
Doctor Compensation
HMO Plan
Partnering with our doctors includes fair compensation for services. There are two ways our providers
receive payment for services:

• Fee-for-service: Each time you are seen for medical care, a bill is sent to us. The doctor is paid
according to a set fee schedule that has been established by us and agreed upon in advance by
the doctor

• Capitation: The provider is paid a set amount every month regardless of how much care you receive
Both methods are based on actual payment practices throughout the U.S.
PPO and EPO Plans
Partnering with our doctors includes fair compensation for services. Our providers get payment for
services through a fee-for-service contract. That means each time you are seen for medical care, a bill
is sent to us. The doctor is paid according to a set fee schedule that has been established by us and
agreed upon in advance by the doctor.
New Technology
It seems like there are new ideas in health care every day. From new drugs to tests to services, we
hear it all the time. We keep up with these new ideas so you can get the best medical care. We make
changes to our benefits and coverage based on these developments when needed. Once we know
there is something new that isn’t a covered benefit, we have our doctors take a very hard and
complete look at it.