ELIGIBILITY

Eligibility

The most fundamental component of managed care is the accurate knowledge of whether a patient is covered under a contracted Health Plan. Getting that data and providing it to contracted physicians in a timely manner is a responsibility AMM takes seriously. To that end, AMM has long-standing relationships with all major Health Plans to receive current eligibility data electronically. This process allows AMM to in-load, compare and update its member files without dependence on outside vendors. As a result, AMM can process eligibility as quickly as it is received from the Health Plans. AMM receives standard HMO eligibility data once each month and that information is available by contacting AMM’s Member Services Department by telephone. On-line access to patient eligibility is also available one day after in-load on AMM’s internet website (amm.cc). AMM's eligibility database can be available real time to IPA Officers or Medical Director on a dial-up basis if an optional host terminal and dedicated phone line is installed at AMM.

AMM routinely provides eligibility reports to providers once each month enclosed with the monthly capitation check. Monthly reconciliation of enrollment and member month statistics are made between HMO provided electronic files and data in EZ-CAP. Variations in eligibility are submitted to the Health Plans for correction. Monthly reporting of eligibility data includes:

  • member listings to PCPs

  • member month calculations to PCPs

  • health plan totals for the IPA

  • PCP totals for the IPA

  • other custom reports as requested