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Prior Authorization

When a doctor or other healthcare provider needs to get approval from a health insurance company before a patient can receive a specific medical service, test, or prescription.

Medicare Advantage Plan

A type of health plan offered by private companies that contracts with Medicare to provide all Part A and Part B benefits, often including additional benefits like prescription drug coverage.

Electronic Prior Authorization Program

A system that allows doctors and health plans to securely send and receive requests and approvals for medical services digitally, rather than through faxes or phone calls.

Social Security Act, Title XVIII

The part of federal law that established and governs the Medicare program, which provides health insurance for Americans aged 65 or older, younger people with certain disabilities, and people with End-Stage Renal Disease.

Enrollee Protection Standards

Rules or guidelines designed to safeguard the rights and interests of individuals who are covered by a health insurance plan, ensuring they receive fair treatment and access to care.

Transparency Requirements

Rules that compel organizations, like health plans, to openly share specific information about their operations, decisions, and outcomes, making their processes more visible to the public and regulators.