CRCR Guide
Health Maintenance Organization (HMO): - answerEnsures comprehensive health
maintenance and treatment services for an enrolled group of persons based on a
monthly fee. The plan will provide the beneficiary with a list of physicians from which
they may choose as their Primary Care Physician (PCP). The beneficiary must contact
their PCP to coordinate their care. The PCP will provide the beneficiary with a referral to
a specialist or obtain pre-cert for non-emergent care. This type of insurance only covers
approved services provided by HMO providers. If the patient goes outside the HMO, the
patient is liable for the total charges.
Preferred Provider Organization (PPO) - answerThis plan is the closest to an indemnity
plan. The employer and the health insurance carrier contract to purchase health care
services from a selected group of participating providers.
These providers agree to follow the utilization management and other procedures that
are implemented by the PPO and agree to accept the PPO reimbursement structure
and payment levels. With this type of plan, the beneficiary may choose to use a non-
PPO provider but will have higher coinsurances and/or deductibles.
Silent PPO's - answerA scheme where insurers that don't offer PPO policies apply the
contracted PPO discounted rate to the patient's bills that are not part of the PPO
network. These payers obtain the database of the preferred provider rates, usually from
a broker. These appear as legitimate discounts on the remittance advice (R/A). See
page 3 of this section for additional information.
Point of Service (POS) - answerAn HMO that offers indemnity type options. The Primary
Care Physician (PCP) usually make referrals to other providers within the plan. But with
the POS plan, the beneficiary may self-refer themselves outside the plan and still have
some coverage. If the PCP refers outside the network, the plan pays all or most of the
bill. If the beneficiary wants to use a provider outside the network and the service is a
covered one, the beneficiary will have higher out of pocket liability
Exclusive Provider Organization (EPO) - answerThis type of plan is similar to the PPO
but unlike PPO's, they limit their beneficiaries to participating providers. Beneficiaries
are required to receive all their care from providers participating in the EPO
Health Maintenance Organization (HMO): - answerEnsures comprehensive health
maintenance and treatment services for an enrolled group of persons based on a
monthly fee. The plan will provide the beneficiary with a list of physicians from which
they may choose as their Primary Care Physician (PCP). The beneficiary must contact
their PCP to coordinate their care. The PCP will provide the beneficiary with a referral to
a specialist or obtain pre-cert for non-emergent care. This type of insurance only covers
approved services provided by HMO providers. If the patient goes outside the HMO, the
patient is liable for the total charges.
Preferred Provider Organization (PPO) - answerThis plan is the closest to an indemnity
plan. The employer and the health insurance carrier contract to purchase health care
services from a selected group of participating providers.
These providers agree to follow the utilization management and other procedures that
are implemented by the PPO and agree to accept the PPO reimbursement structure
and payment levels. With this type of plan, the beneficiary may choose to use a non-
PPO provider but will have higher coinsurances and/or deductibles.
Silent PPO's - answerA scheme where insurers that don't offer PPO policies apply the
contracted PPO discounted rate to the patient's bills that are not part of the PPO
network. These payers obtain the database of the preferred provider rates, usually from
a broker. These appear as legitimate discounts on the remittance advice (R/A). See
page 3 of this section for additional information.
Point of Service (POS) - answerAn HMO that offers indemnity type options. The Primary
Care Physician (PCP) usually make referrals to other providers within the plan. But with
the POS plan, the beneficiary may self-refer themselves outside the plan and still have
some coverage. If the PCP refers outside the network, the plan pays all or most of the
bill. If the beneficiary wants to use a provider outside the network and the service is a
covered one, the beneficiary will have higher out of pocket liability
Exclusive Provider Organization (EPO) - answerThis type of plan is similar to the PPO
but unlike PPO's, they limit their beneficiaries to participating providers. Beneficiaries
are required to receive all their care from providers participating in the EPO
