CRCR Guide
Health Maintenance Organization (HMO): - Answer-Ensures 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) - Answer-This 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 - Answer-A 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) - Answer-An 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
Health Maintenance Organization (HMO): - Answer-Ensures 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) - Answer-This 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 - Answer-A 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) - Answer-An 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
