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Prior authorization, or preauthorization, [1] is a utilization management process used by some health insurance companies in the United States to determine if they will cover a prescribed procedure, service, or medication.
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its medical appropriateness before it is provided, by using evidence-based criteria or guidelines.
In the United States, an exclusive provider organization (EPO) is a hybrid health insurance plan in which a primary care provider is not necessary, but health care providers must be seen within a predetermined network. Out-of-network care is not provided, and visits require pre-authorization.
The prior authorization, or pre-certification process, requires healthcare providers to get coverage approval for certain non-emergency procedures. ... Cigna Group said on Thursday it would remove ...
Nevertheless, according to the trade association America's Health Insurance Plans, 90 percent of insured Americans are now enrolled in plans with some form of managed care. [11] The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts.
Step therapy, also called step protocol or a fail first requirement, is a managed care approach to prescription.It is a type of prior authorization requirement that is intended to control the costs and risks posed by prescription drugs.
Health Insurance Portability and Accountability Act of 1996; Other short titles: Kassebaum–Kennedy Act, Kennedy–Kassebaum Act: Long title: An Act To amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use ...
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