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The Vision
The Mission
Managed IPAs
Departments
Member Bill of Rights








CLAIMS

The Claims Department has the ability to process high volumes of claims. The department staff prides itself on efficient and accurate service. Payment to the providers is usually within thirty (30) days (health plan standard is sixty days). The claims processor processes every claim with precision and speed. Our Claims Department has achieved full delegation by all contracted health plans to process all professional and hospital component of claims.

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CREDENTIALING

Our Credentialing Department maintains IPA's and Medical Group provider files current with NCQA and Health Plan credentialing standards. We utilize the latest technology in tracking information to keep our provider files constantly up-to-date. CHM uses a unique database system that allows fast entry and profile reporting to the health plans. CHM has been delegated by all contracted health plans to carry out the Credentialing Process.

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ELIGIBILITY

The Eligibility department works with our contracted health plans to provide the most up-to-date members' information for our physicians, claims, and utilization management department. CHM provides the physicians a monthly E-List that is user friendly to track the PCP's members. PCP's can take advantage of direct deposit of their capitation for immediate access of funds.

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FINANCE

The Finance Department is responsible for the preparation of the budget and financial forecasts for IPA's and Medical Group. The department evaluates the profitability of each of the health plan's contracts, its products, and assists the outside independent accounting firm in complying with federal and state regulatory requirements. The Finance Department also oversees the Claims, Eligibility and Accounting Departments.

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HEALTH EDUCATION

The Health Education Department offers a wide range of health information topics that are continually disbursed in a brochure format to meet our members' and providers' need. As a subdivision of CHM's Quality Management Department, its goal is to promote a healthy lifestyle and to offer preventive health education to our members. Our members receive a list of preventive care schedule for both adults and pediatrics incorporated in their authorization letter.

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MARKETING/MANAGEMENT

The Marketing and Management staff has accumulated years of experience in the healthcare industry. The group promotes a synergy of innovative concepts and ideas that they believe will allow IPA's and Medical Group to emerge at the forefront of the managed care competition in California. This department designs, creates and manages advertisement campaigns and promotional materials. With a strategic plan, Central Health MSO, Inc. has developed an aggressive approach to outreach the communities.

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MEMBER SERVICES

Health care is a service-driven industry. By providing caring and nurturing services, a satisfied member will refer others to join the IPAs. The member service staffs are thoroughly trained to handle member issues courteously and expediently in order to uphold the standards of our IPA, Health Plans, as well as each individual physician. We educate the physician staff through ongoing in-service sessions to be member advocates, which helps members understand how the system works best for them and therefore keeps patient grievance at a minimum.

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MIS/INFORMATION TECHNOLOGY

Our Information Technology Department is responsible for the flow of current and accurate information between CHM employees, providers, members, and health plans so that decisions that effect tomorrow can be made with confidence today. CHM utilizes advanced computer software to help maintain detailed Provider database and to assist in various essential operations. CHM has integrated sophisticated web-based interactive services, which enables providers to check on the status of claims, preauthorization, and eligibility in real time through internet technology. Providers can also submit claims and preauthorization online.

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PROVIDER RELATIONS

Provider Relations is an integral component in maintaining the cohesiveness of the network. It is extremely important to keep lines of communication open between the providers of health care and Management Company. This department addresses and resolves all concerns of the providers; in addition, they ensure that all network facilities are up to par with health plan regulations. CHM offers monthly group In-Services during lunch hours to accomodate the busy schedules of our providers. In-Services are conducted at two locations at Garfield Medical Center or CHM Covina office. Experienced Provider Relations representative provides step-by-step explanation on claims submission, authorization process, and other vital operational information while lunch is served.

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UTILIZATION & CASE MANAGEMENT

CHM employs it's own in-house UM Department in order to expedite requests for authorizations and to keep referrals within our contracted network. Physician Profile referral statistics and hospital beddays reported monthly gives the IPA's a current overview of their UM activities tied in with their financial status. The Case Manager plays an important role in the monitoring, tracking, and implementation of the utilization and quality of patient care process. More importantly, Case Management carefully monitors patients' status on a daily basis. CHM has Hospitalists to assist PCPs in inpatient admission, which further enhances the quality of care to our members.
The UM/Case Management decision making criteria, UM Program, policies and procedures are available to practitioners, members and the public upon request. This may be through Newsletters and other communications such as the website.

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QUALITY MANAGEMENT & RISK MANAGEMENT

The Quality Management Department oversees all of the quality of care, and quality of service issues of the IPAs. The QM staff, in conjunction with the QM Committee, directly oversees the functions of the Utilization Management, Risk Management, and ongoing provider and member health education. Our trained team also takes an active part in site reviews and in keeping IPA's and our provider offices in compliance. The QM Department meets all NCQA, STATE, DHS, and HEDIS guidelines in monitoring the quality of services of our providers to the members.

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