Process of negotiating and signing an agreement between a managed care plan and provider in which the provider agrees to give medical services to the plan’s members.

Quality program that all Medicare contractors (fiscal intermediaries and regional carriers) are required to have. Contractors must have tools in place to assist physicians and their staff in understanding and complying with Medicare’s operational processes, policies, and billing procedures.

Reference book for members of a managed care plan that alphabetically lists institutions, freestanding surgical centers, and providers who participate in the plan.

Reduced fees for medical services that are negotiated with providers who participate in managed care programs.

Specific total stop loss coverage that is extended to a provider instead of a payer or employer.

Type of medical insurance fraud that is committed by a provider on a patient’s insurance claims so that he or she can obtain benefits in excess of their medical expenses. Also see individual fraud and fraud.

1. Groups of medical providers who give service to managed care plan members and deliver care inexpensively to control health care costs. 2. Providers with whom a Medicare+Choice organization contracts or makes arrangements with to furnish covered health care services to Medicare enrollees under a Medicare+Choice coordinated care or network medical savings account (MSA) plan.