Payment

Date of Publication:

3/13/2019

Definition:

Except as prohibited by Paragraph 4.4.j of DODM 6025.18: The activities undertaken by a health plan to obtain premiums or to determine or fulfill its responsibility for coverage and provision of benefits under the health plan; or a health care provider or health plan to obtain or provide reimbursement for the provision of health care. Payment activities relate to the individual to whom health care is provided and include, but are not limited to: Determinations of eligibility or coverage including coordination of benefits or the determination of cost sharing amounts, and adjudication or subrogation of health benefit claims.  Risk adjusting amounts due based on enrollee health status and demographic characteristics. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance), and related health care data processing. Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges. Utilization review activities, including pre-certification and preauthorization of services, concurrent and retrospective review of services. Disclosure to consumer reporting agencies of any of the following PHI relating to collection of premiums or reimbursement: name and address; date of birth; social security number; payment history; account number; and name and address of the health care provider or health plan.