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 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. Formally Enrolled with a Continuing Care Provider (as cited in 42 CFR 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, itself or some other person or entity. It includes any act that constitutes fraud under applicable federal or state law.

Split View

AI-Powered Contracts

Draft, Review & Redline at the Speed of AI

Get StartedSchedule a Demo

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.

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

Examples of Enrollment Specialist in a sentence

• Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program.

• The HMO may request assistance from the Department’s contracted Enrollment Specialist in situations where the member has commercial insurance that limits the members to providers outside the HMO’s network.

• Exemption requests should be directed to the Department’s Enrollment Specialist.

• The HMO must direct all members with exemption requests to the Department’s Enrollment Specialist for assistance and/or choice counseling.

• The HMO must direct all members with involuntary disenrollment requests to the Department’s Enrollment Specialist for assistance and/or for choice counseling.

• The HMO does not need to report this population to the Enrollment Specialist as the disenrollment is automatic.

• The member requests this exemption and it is approved by the Enrollment Specialist or fiscal agent.

• The telephone number of both the Enrollment Specialist and the Ombudsman.

• The PIHP must direct all members with involuntary disenrollment requests to the Department’s Enrollment Specialist for assistance and/or for choice counseling.

• The PIHP must direct all members with disenrollment requests to the Department’s Enrollment Specialist for assistance and/or for choice counseling.

More Definitions of Enrollment Specialist

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.