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



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


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


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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