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Prior Authorization

A process where a doctor or other healthcare provider must get approval from a patient's health insurance company before providing a specific medical service, treatment, or prescription.

Medicare Advantage Plans

Health insurance plans offered by private companies that contract with Medicare to provide all your Part A (hospital insurance) and Part B (medical insurance) benefits. They often include extra benefits like vision, hearing, and dental.

Electronic Prior Authorization

A system where doctors and insurance companies exchange prior authorization requests and responses digitally, using secure electronic methods, rather than faxes or paper forms.

Social Security Act, Title XVIII

The section of the federal law that established the Medicare program, which provides health insurance for most Americans aged 65 or older, and younger people with certain disabilities.

Enrollee Protection Standards

Specific rules designed to safeguard the rights and interests of individuals enrolled in a health plan, ensuring they receive fair treatment and timely access to care, especially concerning processes like prior authorization.

Transparency Requirements

Rules that require health plans to openly share specific information, such as data on prior authorization decisions, approval rates, and decision-making processes, to increase public accountability and understanding.