Enrollment Specialist definition

Enrollment Specialist. An entity contracted by the Department to perform HMO choice counseling and HMO enrollment activities. Choice counseling refers to activities such as answering questions and providing unbiased information on available managed care organization delivery system options, and advising on what factors to consider when choosing among HMOs and in selecting a primary care provider. Enrollment activities refers to distributing, collecting, and processing enrollment materials and taking enrollments by phone, by mail, or in person. Enrollment Year: An enrollment year is defined as the continuous 12-month period beginning the first day of the calendar month in which a member is enrolled in the Benchmark or Core Plans and ending on the last day of the 12th calendar month. Further information is available in the BadgerCare Plus All-Provider Updates.
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Enrollment Specialist. An entity contracted by the Department to perform HMO choice counseling and HMO enrollment activities. Choice counseling refers to activities such as answering questions and providing unbiased information on available managed care organization delivery system options, and advising on what factors to consider when choosing among HMOs and in selecting a primary care provider. Enrollment activities refers to distributing, collecting, and processing enrollment materials and taking enrollments by phone, by mail, or in person. Estimated Data Completeness: A measure used by the Department to evaluate HMO compliance with encounter submission requirements. Excluded Services: Services that Medicaid does not pay for. Expedited Grievance or Appeal: An emergency or urgent situation in which a member or their authorized representative requests a review of a situation where further delay could be a health risk to the member, as verified by a medical professional. Experimental Surgery and Procedures: Experimental services that meet the definition of Wis. Adm. Code DHS 107.035(1) and (2) as determined by the Department. External Quality Review (EQR): Per 42 CFR §438.320, the analysis and evaluation by an External Quality Review Organization of aggregated information on quality, timeliness, and access to the health care services that an HMO or their contractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO): Per 42 CFR §438.320, an organization that meets the competence and independence requirements set forth in 42 CFR §438.354, and performs external quality review, other EQR-related activities as set forth in 42 CFR §438.358, or both. Fiscal Agent (as cited in 42 CFR §455.101): A contractor that processes or pays vendor claims on behalf of the Medicaid agency. Formally Enrolled with a Continuing Care Provider (as cited in 42 CFR §441.60(d)): A member, member’s guardian, or authorized representative agrees to use one continuing care provider as the regular source of a described set of services for a stated period of time. ForwardHealth interChange: ForwardHealth interChange handles claims, prior authorizations, and other services for many of the state health care programs within a single system. Throughout this contract, the system is referred to as “interChange.” Fraud: An intentional deception or misrepresentation made by a person or entity with the knowledge that the deception could result in some unauthorized benefit to him/herself, itsel...
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Enrollment Specialist. An entity contracted by the Department to perform HMO choice counseling and HMO enrollment activities. Choice counseling refers to activities such as answering questions and providing unbiased information on available managed care organization delivery system options, and advising on what factors to consider when choosing among HMOs and in selecting a primary care provider. Enrollment activities refers to distributing, collecting, and processing enrollment materials and taking enrollments by phone, by mail, or in person. Estimated Data Completeness: A measure used by the Department to evaluate HMO compliance with encounter submission requirements. It is calculated by multiplying the pricing submitted by the pricing percentage for a defined time period such as a Calendar or Fiscal Year.
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Examples of Enrollment Specialist in a sentence

  • The Enrollment Specialist will obtain provider information from new members whenever possible and share that information with the HMO.

  • The Enrollment Specialist will obtain provider information from new members whenever possible and share the information with the assigned HMO.


More Definitions of Enrollment Specialist

Enrollment Specialist means the Tribal official whose duty it is to verify enrollment in the Tribe.
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Related to Enrollment Specialist

  • Enrollment means the number of students who are enrolled in a school operated by the district on October 1. A student shall be counted as one whether the student is enrolled as a full-time or part-time student. Students enrolled in prekindergarten programs shall not be counted.

  • Benefits Specialist means a specialized position that would primarily be responsible for coordinating Client applications and appeals for State and Federal benefits.

  • Declining enrollment means a decrease in the District's total enrollment or enrollment in a particular program or curricular / instructional offering which in the sole judgment of the board of education may adversely affect the District's current or future funding and/or the necessity of maintaining certain current or future class sections or curricular / instructional offerings.

  • Peer support specialist means an individual who has experienced a severe and persistent mental illness and who has successfully completed standardized training to provide peer support services through the medical assistance program or the Iowa Behavioral Health Care Plan.

  • Open enrollment means a period of time as defined in rule

  • Clinical nurse specialist means a registered nurse with relevant post-basic qualifications and 12 months’ experience working in the clinical area of his/her specified post-basic qualification, or a minimum of four years’ post-basic registration experience, including three years’ experience in the relevant specialist field and who satisfies the local criteria.

  • Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Enrollment Form means an agreement pursuant to which an Eligible Employee may elect to enroll in the Plan, to authorize a new level of payroll deductions, or to stop payroll deductions and withdraw from an Offering Period.

  • Non-Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Random selection process means a process by which currently income-eligible households are selected for placement in affordable housing units such that no preference is given to one applicant over another except for purposes of matching household income and size with an appropriately priced and sized affordable unit (e.g., by lottery).

  • Expedited review means an examination, in accordance with

  • Participating Retail Health Clinic means a Retail Health Clinic which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Random selection basis means a mechanism for selection of employees that:

  • Design Criteria Professional means a firm who holds a current certificate of registration under Chapter 481 of the Florida Statutes, to practice architecture or landscape architecture, or a firm who holds a current certificate as a registered engineer under Chapter 471 of the Florida Statutes, to practice engineering, and who is employed by or under contract to the District to provide professional architect services, landscape architect services, or engineering services in connection with the preparation of the Design Criteria Package.

  • Participating Prescription Drug Provider means an independent retail Pharmacy, chain of retail Pharmacies, mail-order Pharmacy or specialty drug Pharmacy which has entered into an agreement to provide pharmaceutical services to participants in the benefit program. A retail Participating Pharmacy may or may not be a select Participating Pharmacy as that term is used in the Vaccinations Obtained Through Participating Pharmacies section.

  • Selection Criteria means and includes all of the requirements, considerations,