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After a request comes in from a qualified provider, the request will go through the prior authorization process. The process to obtain prior authorization varies from insurer to insurer but typically involves the completion and faxing of a prior authorization form; according to a 2018 report, 88% are either partially or entirely manual.
Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
Aetna Inc. (/ ˈ ɛ t n ə / ET-nə) is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare.
In 2015 CMS identified 254 quality measures for which providers may choose to submit data. The measures map to U.S. National Quality Standard (NQS) health care quality domains: [4]
Dr. Paul Starr suggests in his analysis of the American healthcare system (i.e., The Social Transformation of American Medicine) that Richard Nixon, advised by the "father of Health Maintenance Organizations", Dr. Paul M. Ellwood Jr., was the first mainstream political leader to take deliberate steps to change American health care from its ...
In October 2000, the company acquired WellPath, the managed care subsidiary of Duke University Health System, for $20.7 million. [4] In October 2010, the company acquired MHP (Mercy Health Plans), an insurer with approximately 180,000 members in Missouri and northwest Arkansas. [5]
The X12 834 EDI Enrollment Implementation Format is a standard file format in the United States for electronically exchanging health plan enrollment data between employers and health insurance carriers.
Aetna Inc. is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare.