Prime Care Consultants, LLC

Exclusive Provider Organization

An EPO is a form of PPO, in which patients must visit a caregiver that is specified on its panel of providers (is a participating provider). If a visit to an outside(not participating) provider is made the EPO offers very limited or no coverage for the medical service; (2) While similar to a PPO in that an EPO allows patients to go outside the network for care, if they do so in an EPO, they are required to pay the entire cost of care. An EPO differs from an HMO in that EPO physicians do not receive capitation but instead are reimbursed only for actual services provided; (3) An organization identical to a preferred provider organization except that persons enrolled in the plan are eligible to receive benefits only when they use the services of the contracting providers. No benefits are available when non-contracting providers are used, except in certain emergency situations.

Case Management Agency

An organization that is responsible for providing case management services. The agency provides services which assist an individual in gaining access to needed medical, social, educational, and/or other services. Case management services may be used to locate, coordinate, and monitor necessary appropriate services. It may be used to encourage the use of cost-effective medical care by referrals to appropriate providers and to discourage over utilization of costly services. Case management may also serve to provide necessary coordination of non-medical services such as vocational rehabilitation, education, employment, when the services provided enable the individual to function at the highest level.