Final answer:
The 'Utilization Management' section of a managed care contract details the rules for referrals and preauthorization, which are essential for providers and patients in following the correct procedures to ensure service coverage and reimbursement.
Step-by-step explanation:
The section of a managed care participation contract that covers referrals and preauthorization rules is often termed as the 'Utilization Management' or 'Medical Management' section of the contract. This section outlines the procedures for obtaining approval for certain medical services in advance, the referral process to see specialists, and how the managed care organization requires notification for emergency and urgent care. It also addresses the consequences of failing to follow these rules, which can include denial of payment for services rendered.
Understanding the preauthorization and referrals process is vital for both patients and healthcare providers as it affects accessibility to medical services and reimbursement. Terms like managed care, fee-for-service, and health maintenance organizations (HMOs) are central to grasping how these contracts function in the healthcare industry. In addition, knowledge about these terms and concepts is also essential to comprehend the broader health financial systems such as Medicare, Medicaid, and the regulations that come with the Affordable Care Act (ACA or Obamacare).