2.2Genesis Of Healthcare
2.3How the industry Works?
3.2.1Insurance Business: An Overview
3.3Individual and Group Insurance in detail
3.3.2How to get individual insurance?
3.3.4Company Paid Groups
3.3.6Self Insured Group
3.4.1What is Enrollment?
3.4.2How is enrollment carried out?
3.4.3Output of enrollment process
3.4.4Enrollment: Overall Picture
3.5Member’s and Dependent’s eligibility
3.5.3How a member should approach right provider?
3.5.4Eligibility Data Transfer
3.6.1Means of services
3.8Member Group Maintenance
3.8.1What are Groups?
4.3.1 Provider Contract Process
4.3.2 Credentialing Criteria
4.3.3 Verification of Provider Credentialing Information
4.3.4 Types of Contracts
4.3.5 Provider Reimbursement
4.5.1 Referrals processing
4.7.1 some common information of Providers
5.3.1Calculation for Brokers
5.4.1What is a quote?
5.4.2The Process Of Quote Creation
5.7Insurance Payer’s Sales Department
5.7.1External Agents that deal with Sales Department of Insurance Payers
6.4Managed Care Plans
6.4.1Health Maintenance Organization (HMO)
6.4.2Preferred Provider Organization (PPO)
6.4.3Point Of Service (POS)
6.4.4Exclusive Provider Organization (EPO)
6.5Which plan is the best?
6.6.7Long Term Care
6.6.8Disability Income Insurance
6.6.9Catastrophic Coverage Plans
6.8Laws and Legislations
6.8.1Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
6.8.2Health Insurance Portability and Accountability Act (HIPAA)
7.1Claim generation and submission to Providers
7.1.1Claims Intake Process
7.1.2Claims Intake : Diagrammatic
7.2Claim Adjudication Process
7.2.1Claim Preparation and determining eligibility
7.2.4Claim adjudication outputs
7.4.2Minus Debit Adjustment
7.4.3Manual Check Adjustment
7.6Explanation of Benefits (EOB)
126.96.36.199.1What are Accumulators?
188.8.131.52.2Function/Purpose of Accumulators
7.7.3What is accumulated?
7.8Overall Claims system diagram :
8.3.1Centers for Medicare & Medicaid Services (CMS)
8.3.2DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHSS)
8.3.3Centers for Disease Control and Prevention (CDC)
8.3.4Agency for Health Care Research and Quality (AHRQ)
8.3.6Health Resources and Services Administration (HRSA)
8.4Government Acts and Regulations
8.5.1Benefits Of A Clearinghouse
8.5.2Clearinghouse versus Direct Filing
8.6Third Party Administrators
8.7Specialized Adjudication Engines/Companies
8.9.1The Accreditation Process
9.2.1The Beginning: Member wants to purchase insurance
9.2.2Getting a provider
9.2.3An Enrolled member wants to seek medical services
9.2.4 Member has filed a claim
9.2.5Effect of external agencies
10.1Appendix A: Total E-Business Services Forecast for Healthcare
10.2Appendix B: The world Healthcare market and Healthcare IT spending
(Source: Gartner Research, Inc)
10.3Appendix C: The Cash Flux of the US Healthcare Industry
10.4Appendix C: Sample Quote Sheet