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  2. Prior authorization - Wikipedia

    en.wikipedia.org/wiki/Prior_authorization

    After a request comes in from a qualified provider, the request will go through the prior authorization process. The process to obtain prior authorization varies from insurer to insurer but typically involves the completion and faxing of a prior authorization form; according to a 2018 report, 88% are either partially or entirely manual.

  3. Utilization management - Wikipedia

    en.wikipedia.org/wiki/Utilization_management

    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.

  4. Pharmacy benefit management - Wikipedia

    en.wikipedia.org/wiki/Pharmacy_benefit_management

    In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans.

  5. Blue Cross and Blue Shield of Alabama - Wikipedia

    en.wikipedia.org/wiki/Blue_Cross_and_Blue_Shield...

    Blue Cross and Blue Shield of Alabama (BCBSAL) is a nonprofit health insurance company headquartered in Birmingham, Alabama. The company was founded in 1936, provides coverage to more than 3 million people and is a member of the Blue Cross and Blue Shield Association (BCBS). BCBSAL employs nearly 5,000 people, which includes almost 3,500 people ...

  6. Blue Cross Blue Shield of Michigan - Wikipedia

    en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_of...

    Blue Cross Blue Shield of Michigan (BCBSM) is an independent licensee of Blue Cross Blue Shield Association. [1] Currently it is headquartered in 600 E. Lafayette Blvd. in downtown Detroit. Blue Cross Blue Shield of Michigan, a nonprofit mutual insurance company, provides and administers health benefits to more than 4.3 million members residing ...

  7. Health maintenance organization - Wikipedia

    en.wikipedia.org/wiki/Health_maintenance...

    The Farmer's Union took control of the hospital and the health plan in 1934. Also in 1929, Baylor Hospital provided approximately 1,500 teachers with prepaid care. This was the origin of Blue Cross. Around 1939, state medical societies created Blue Shield plans to cover

  8. Managed care - Wikipedia

    en.wikipedia.org/wiki/Managed_care

    Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.

  9. Preferred provider organization - Wikipedia

    en.wikipedia.org/wiki/Preferred_provider...

    Another near-universal feature is a pre-certification requirement, in which scheduled (non-emergency) hospital admissions, and in some instances, outpatient surgery, must have the prior approval of the insurer and must often undergo "utilization review" in advance.

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