Word applied to women who are eligible for Social Security benefits based on federal legislation developed by Senator Prouty.

1. Licensed physician or any qualified health care practitioner who provides health care services to the patient and is legally accountable for establishing patient diagnoses. If a medical doctor, the provider can be the attending, ordering, treating, performing, or referring physician. 2. Organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, dentists, pharmacists, ambulatory surgical centers, home health care agencies, skilled nursing facilities, and outpatient clinics are some of the service providers covered under Medicare Part B. 3. In a 401(k) defined-contribution pension plan, a financial services company that offers the mutual funds and other investment choices.

Method the member of a managed care plan may use for the handling of dissatisfaction and unfair treatment against a provider.

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.