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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 ...
Provider enrollment is the process of enrolling a provider with insurance payers. The provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. While hospitals and health systems typically have their own provider enrollment team to perform this function ...
Open enrollment for 2025 Medicare plans runs through December 7. Some major changes in 2025 include a new $2,000 out-of-pocket max under Part D, eliminating the plan’s “donut hole” coverage ...
by health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans; by electronic patient record systems to identify treating health care providers in patient medical records;
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. The Health Insurance Portability and Accountability Act (HIPAA) requires that all health plans or health insurance carriers accept a standard ...
[1] [2] Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. [3] Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. [4] Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries. [5]
(The requirement itself is still in effect.) [57] In 2019 Congress repealed the so-called "Cadillac" tax on health insurance benefits, an excise tax on medical devices, and the Health Insurance Tax. [97] The American Rescue Plan Act of 2021, enacted during the COVID-19 pandemic in the United States, expanded subsidies for marketplace health plans.
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