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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 ...
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Third-party administrators are prominent players in the health care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other ...
CalOptima is a publicly funded health insurance plan for low-income citizens for Orange County, CA. With an annual budget of US$4 billion serving 940,000 members as of July 2022, [ 1 ] it is also the single largest county organized health insurer in the state. [ 2 ]
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Self-funded health care, also known as Administrative Services Only (ASO), is a self insurance arrangement in the United States whereby an employer provides health or disability benefits to employees using the company's own funds. [1]
Again, using U.S. health coverage as an example, under group insurance a person will normally remain covered as long as he or she continues to work for a certain employer and pays the required insurance premiums, whereas under individual coverage, the insurance company often has the right not to renew an individual health insurance policy if ...
GEHA (Government Employees Health Association) is a self-insured, not-for-profit association providing medical and dental plans to federal employees and retirees and their families through the Federal Employees Health Benefits program and the Federal Employees Dental and Vision Insurance Program (FEDVIP).