Provider Networks

Policy Definition: A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members. This can be a method of organizing providers to direct consumers to high-quality, effective, and low-cost care. These providers are called “network providers” or “in-network providers.” source

Accreditation

Policy Definition: Accreditation is a comprehensive evaluation process in which a health care organization’s systems, processes and performance are examined by an impartial external organization (“accrediting body”) to ensure that it is conducting business in a manner that meets predetermined criteria and is consistent with national regulatory and safety/quality standards. source

Third Party Administrator

Policy Definition: Third party administrators are outside organizations that process insurance claims but do not bear risk. Third party administrators can also manage healthcare expenses through increasing system efficiencies to reduce individual costs. source

Pharmacy Benefit Managers

Policy Definition: Pharmacy benefit managers (PBMs) are companies that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. PBMs implement programs to help contain expenditures for the manager/payer and individual. source