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Keystone First is a medical assistance (Medicaid and Medicare) managed care health plan based in southeastern Pennsylvania. Keystone focuses on low-income residents in southeastern Pennsylvania counties including, Bucks, Chester, Delaware, Montgomery, and Philadelphia. The healthcare provider currently serves over 400,000 residents in the area. [1]
The community health center (CHC) in the United States is the dominant model for providing integrated primary care and public health services for the low-income and uninsured, and represents one use of federal grant funding as part of the country's health care safety net. The health care safety net can be defined as a group of health centers ...
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 ...
Health Partners Plans was founded in 1984 and is one of the few hospital-owned health maintenance organizations. The organization had been owned jointly by Jefferson Health, Einstein Healthcare Network and Temple University Health System, but Jefferson Health became the sole owner of Health Partners Plans in November 2021.
Medicare pays for medical items and services that are "reasonable and necessary" or "appropriate" for a variety of purposes. [1] By statute, Medicare may pay only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" unless there is another statutory authorization for payment.
Physician's News Digest article on Certificates of Medical Necessity; Statutory definition of a CMN at the SSA website; Medicare manual that provides exhaustive information about the practical use of CMNs, particularly section 5.3. This is the official source of information for contractors administering the Medicare system about the use of CMNs.
The National Uniform Billing Committee (NUBC) is the governing body for forms and codes use in medical claims billing in the United States for institutional providers like hospitals, nursing homes, hospice, home health agencies, and other providers. The NUBC was formed by the American Hospital Association (AHA) in 1975. [3]