vocabulary: provider: WellCare Health Plans (Centene) description: >- Vocabulary for WellCare Health Plans, a Centene subsidiary providing Medicaid, Medicare Advantage, and Medicare Prescription Drug Plans. Covers managed care, FHIR interoperability, healthcare data exchange, and CMS compliance terminology. tags: - Healthcare - Managed Care - Medicaid - Medicare - FHIR - Interoperability domains: - name: Plan Types and Programs terms: - term: Medicaid definition: Joint federal-state health coverage program for low-income individuals managed by WellCare under state contracts. - term: Medicare Advantage definition: Medicare Part C private health plan alternative offered by WellCare with additional benefits beyond Original Medicare. - term: Medicare Prescription Drug Plan definition: Medicare Part D standalone prescription drug coverage plan offered by WellCare. - term: SNP (Special Needs Plan) definition: Medicare Advantage plan tailored for individuals with specific diseases, dual eligibility, or institutional care needs. - term: Dual Eligible definition: Member eligible for both Medicaid and Medicare simultaneously. - term: Centene definition: Parent company that acquired WellCare Health Plans, operating as one of the largest managed care organizations in the US. - name: Member and Care Management terms: - term: Member definition: An individual enrolled in a WellCare health plan. - term: Member ID definition: Unique identifier assigned to each WellCare plan member. - term: Care Management definition: Coordinated programs to help members manage chronic conditions and navigate the healthcare system. - term: Case Manager definition: Clinical professional who coordinates care for high-risk WellCare members. - term: Prior Authorization definition: Approval required from WellCare before certain services or medications are covered. - term: Formulary definition: List of prescription drugs covered under a WellCare Medicare Part D or Medicaid plan. - name: FHIR and Interoperability terms: - term: FHIR definition: Fast Healthcare Interoperability Resources - HL7 standard for exchanging healthcare data electronically. - term: FHIR R4 definition: Release 4 of the FHIR standard, the version required by CMS interoperability rules. - term: SMART on FHIR definition: OAuth 2.0-based authorization framework for FHIR-enabled health apps accessing member data. - term: Patient Access API definition: CMS-required FHIR API allowing members to access their health data through third-party apps. - term: Provider Directory API definition: CMS-required FHIR API providing machine-readable in-network provider directory data. - term: CMS-9115-F definition: CMS Interoperability and Patient Access final rule requiring Medicaid and Medicare Advantage plans to publish FHIR APIs. - term: EOB (Explanation of Benefits) definition: FHIR ExplanationOfBenefit resource representing an adjudicated claim showing services, costs, and payments. - term: Da Vinci PDex Plan-Net definition: HL7 implementation guide for FHIR-based provider directory data exchange. - name: Claims and Benefits terms: - term: Claim definition: Request for payment submitted to WellCare by a provider for services rendered. - term: Adjudication definition: WellCare's process of evaluating and processing a claim for payment. - term: Copay definition: Fixed out-of-pocket amount a member pays for a covered service. - term: Coinsurance definition: Percentage of costs a member pays after meeting the deductible. - term: Deductible definition: Amount a member pays out-of-pocket before WellCare coverage begins. - term: Out-of-Pocket Maximum definition: Maximum amount a member pays in a plan year before WellCare covers 100% of covered costs. - term: HEDIS definition: Healthcare Effectiveness Data and Information Set - performance measures used to evaluate health plan quality. - name: Provider Network terms: - term: In-Network definition: Healthcare provider who has contracted with WellCare to provide services at negotiated rates. - term: Out-of-Network definition: Provider who has not contracted with WellCare; may result in higher member cost-sharing. - term: NPI definition: National Provider Identifier - 10-digit standard identifier for healthcare providers. - term: PCP (Primary Care Provider) definition: Provider responsible for coordinating a member's overall healthcare. - term: Specialist definition: Provider with advanced training in a specific area of medicine. - term: Taxonomy Code definition: NUCC Health Care Provider Taxonomy code classifying a provider's specialty.