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Overview. Prior authorization is a check run by some insurance companies or third-party payers in the United States before they will agree to cover certain prescribed medications or medical procedures. [1] There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a ...
t. e. The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("managed care techniques"). It has become the predominant system of delivering and receiving ...
Step therapy. 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. The practice begins medication for a medical condition with the most cost-effective drug ...
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 health insurance policy is: A contract between an insurance provider (e.g. an insurance company or a government) and an individual or his/her sponsor (that is an employer or a community organization). The contract can be renewable (annually, monthly) or lifelong in the case of private insurance. It can also be mandatory for all citizens in ...
We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition." [ 24 ] In a March 3, 2010, address, President Barack Obama said that coverage denied to those with pre-existing conditions is a serious problem that would only grow worse without major reforms. [ 25 ]
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 ...
The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy – Kassebaum Act[1][2]) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996. [3] It aimed to alter the transfer of healthcare information, stipulated the guidelines by ...