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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]
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 ...
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 ]
A Health Reimbursement Arrangement, also known as a Health Reimbursement Account (HRA), [1] is a type of US employer-funded health benefit plan that reimburses employees for out-of-pocket medical expenses and, in limited cases, to pay for health insurance plan premiums.
The Knox-Keene Health Care Service Plan Act of 1975 is a set of Californian laws that regulate Healthcare Service Plans. Under these laws, pharmacy benefit managers with contracts to Health care service plans are required by law to be registered with the Department of Managed Health Care to disclose information. [58] SB 966: Pharmacy benefits
Selling insurance products under UnitedHealthcare, and health care services under the Optum brand, it is the world's ninth-largest company by revenue and the largest health care company by revenue. The company is ranked 8th on the 2024 Fortune Global 500. [4] UnitedHealth Group had a market capitalization of $460.3 billion as of December 20, 2024.
A 1998 report to the Health Care Financing Administration (now known as the Centers for Medicare and Medicaid Services) noted that in the five years of the demonstration project, the seven hospitals would have had expenditures of $438 million for coronary artery bypasses for Medicare beneficiaries, but the change in reimbursement methodology ...
In U.S. health insurance, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at ...