Definition: Set of codes indicating the manner in which payors participate in a policy or program.</

Definition: Manages all operations required to adjudicate fee for service claims or managed care encounter reports.

Definition: Managing the enrollment of covered parties.

Definition: Managing all operations required to administer a fee for service or indemnity health plan including enrolling covered parties and providing customer service, provider contracting, claims payment, care management and utilization review.

Definition: Managing all operations required to administer a managed care plan including enrolling covered parties and providing customer service,, provider contracting, claims payment, care management and utilization review.

Definition: Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.

Definition: Managing utilization of services by ensuring that providers adhere to, e.g., payeraTMs clinical protocols for medical appropriateness and standards of medical necessity. May include management of authorizations for services and referrals.