Patient Management Programs definition

Patient Management Programs means any program administered by Health Options or its subsidiaries that require pre- authorization and Case Management of benefits for those Members who have incentives to seek care from Participating Providers, or which embody such plan characteristics. Payment means the total amount to be collected by a Participating Provider from Health Options for a Medically Necessary Covered Service rendered to a Member calculated as the lower of the Participating Provider's actual billed charge or the Payment Schedule less any applicable Copayments, coinsurance and/or deductibles. Payment Schedule means the schedule of specified maximum allowable payment amounts for Medically Necessary Covered Services applicable to certain Member contracts as calculated by various methodologies, including but not limited to RBRVS, as determined by Health Options. Point of Service (POS) means a benefit program in which Members select a primary care physician and maximize benefit coverage when securing care directly from, or under authorization by, the selected Physician. Conversely, Members may incur additional out-of-pocket costs or reduced benefits for using non-network providers. Preferred Provider Organization (PPO) means a benefit program in which Members receive higher benefit levels when care is obtained from a network Participating Provider than if the Member were to receive care from a non-network provider.