BUILDING BLOCKS > MANAGER

Benefit Administration and  Organization

How does the system organize and deliver services?

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Provider Networks

How are networks organized to ensure consumers have access to high-quality, effective, and low-cost care?

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. These providers are called “network providers” or “in-network providers.” source

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Accreditation

How do provider entities demonstrate their ability to meet regulatory requirements and standards, and how does the process impact safety and/or quality of care?

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 standards. source

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Third Party Administrator

Does utilizing an outside entity to reimburse and manage health care expenses increase system efficiency and reduce individual costs?

Policy Definition: Outside organization that processes insurance claims but does not bear risk. Entity needed for self-funded health plans. source

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Pharmacy Benefit Managers

Does using an external organization to administer a drug benefit program (Or a prescription coverage plan) help contain expenditures for the manager/payer and individual?

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. source

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