Payment Policy Term Definition

Any activities undertaken by a health plan or health care provider to obtain a premium or fulfill its responsibility for coverage and the provision of benefits, or to obtain or provide reimbursement for the provision of health care. These activities include, but are not limited to:

1. Determining eligibility and adjudication or subrogation of health benefit claims;
2. Risk adjusting amounts due based on enrollee health status and demographic characteristics;
3. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related health care processing;
4. Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges;
5. Utilization review activities, including pre-certification and preauthorization services and concurrent and/or retrospective review of services; and
6. Disclosure to consumer reporting agencies of certain PHI relating to collection of premiums or reimbursement.