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A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [2] Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4]
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 ...
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards.
Blue Cross Blue Shield insurers offer some form of health insurance coverage in every U.S. state, and also act as administrators of Medicare in many states or regions of the United States, and provide coverage to state government employees as well as to federal government employees under a nationwide option of the Federal Employees Health ...
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), (H.R. 2, Pub. L. 114–10 (text)) commonly called the Permanent Doc Fix, is a United States statute.. Revising the Balanced Budget Act of 1997, the Bipartisan Act was the largest scale change to the American health care system following the Affordable Care Act
The generic model used in the United States is the chronic care model, which holds that health care does not only involve change in the patient and that high-quality disease care counts the community, the health system, self-management support, delivery system design, decision support, and clinical information systems as important elements in ...
HealthCare.gov is a health insurance exchange website operated by the United States federal government under the provisions of the Affordable Care Act (ACA), informally referred to as "Obamacare", which currently serves the residents of the U.S. states which have opted not to create their own state exchanges.
The McCarran–Ferguson Act, 15 U.S.C. §§ 1011-1015, is a United States federal law that exempts the business of insurance from most federal regulation, including federal antitrust laws to a limited extent. The 79th Congress passed the McCarran–Ferguson Act in 1945 after the Supreme Court ruled in United States v.