How to Use This Map

This page explains how the field map is organized, what the callouts mean, and how to navigate it so you can read efficiently instead of clicking at random. Read it once to familiarise yourself with the content included. It'll make everything stop feeling like a pile of notes and start feeling like a system.

How the guide is organized

The map is a Home page, a Start Here folder of three orientation pages (this one, the mental model, and the glossary), and twelve numbered sections. Every section is a Map of Content (MOC) which is a hub page that links down to the individual pages inside it. You can read a whole section by opening its MOC and following the links.

The twelve sections run in a deliberate order and build on each other. I don't think my mental model is the cleanest, but it works. So reading roughly top-to-bottom gives you an appreciation similar to mine. However, I used Claude to ensure every page can stand on it's own so jumping in mid-guide is fine too.

1. The Stakeholders — who is in the game: payers, providers, employers, members, regulators, TPAs, PBMs.
2. How Money Flows — the premium dollar, the claims lifecycle, fee schedules, and the MLR.
3. Coverage & Benefits — what a plan covers: benefit design, plan types, networks, eligibility, and the front door of Prior Authorization.
4. Utilization Management — the control layer: clinical criteria, medical necessity, reviews, appeals, and regulatory clocks. Its own sub-MOC, Utilization Management by Service Line, shows how that control plays out across imaging, surgery, behavioral health, DME, and more.
5. Care Management & Population Health — managing members rather than dealing with claims.
6. Clinical Data, Coding & Interoperability — the data substrate: coding systems, the EHR, FHIR, and the exchange rules.
7. Payment & Program Integrity — keeping the money honest: claims editing, FWA, audits, recovery.
8. Pharmacy & PBMs — the drug supply chain and the intermediaries that coordinate it.
9. Value-Based Care & Risk — paying for outcomes instead of volume.
10. Regulation & Policy — the rulebook: HIPAA, ERISA, the ACA, the No Surprises Act, and the CMS rules that continue to reshape the industry.
11. The Vendor Landscape — who sells what, and the build-vs-buy map.
12. Where It Breaks & Where AI Wins — the capstone: a read on where the system strains today and where software and AI can genuinely improve it to bring better Healthcare for all.

What the callouts mean

I'm writing this in an Obsidian Vault which means everything is a long wall of text. To break things up for my own sanity, and hopefully to make the content more digestible for the reader, I have pulled out the call outs. Everything in the body is sourced (thanks again, Claude!) and everything in the callouts is... not. There are four:

How to navigate

There are three ways through the guide, and you'll use all of them.

• By MOC. Start at Home or any numbered section MOC and follow the links down. This is the structured path best for when you're new or want full coverage of a topic.
• By link. The first mention of any concept with its own page is a wikilink. Follow your curiosity: every page connects to its neighbours, so you can read laterally — from Prior Authorization to Utilization Review to Clinical Criteria (MCG & InterQual) without ever returning to a hub.
• By graph and search. Obsidian's local graph shows you what a page connects to; the global graph shows the whole field at once. Aliases mean acronyms resolve too — searching PA , UM , MLR , or HCC lands you on the right page. The Glossary & Acronyms page is the index for all of them. At the time of publishing, I haven't found a way to make this accessible yet and instead I am working on making the guide available to your preferred LLM chatbot instead.

Reading paths by reader

You don't need all twelve sections. Pick the path that matches why you're here.

• Founder building in healthtech. The 90-Second Mental Model → Where It Breaks & Where AI Wins → The Prior Authorization Problem → The Automation Opportunity Map → The Founder's Theses → Building & Selling Healthtech (Go-to-Market). This is the where-to-build path.
• Product manager. The 90-Second Mental Model → Utilization Management → The Prior Authorization Workflow → Utilization Management by Service Line → Clinical Data, Coding & Interoperability. The workflows you'll actually design around.
• Investor. Home → How Money Flows → The Premium Dollar → Medical Loss Ratio (MLR) → Value-Based Care & Risk → The Vendor Landscape → The Founder's Theses. Where the dollars sit and who captures them.
• Clinician-curious. The Stakeholders → Medical Necessity → Utilization Review → Appeals & Grievances → Peer-to-Peer Review. The admin machinery that sits behind the care you already understand.
• Policy and compliance. Regulation & Policy → HIPAA → ERISA & Self-Funded Plans → The No Surprises Act → The CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F). The rulebook and what's changing now.

Related

• Home
• The 90-Second Mental Model
• Glossary & Acronyms
• The Stakeholders
• How Money Flows
• Coverage & Benefits
• Utilization Management
• Regulation & Policy
• The Vendor Landscape
• Where It Breaks & Where AI Wins
• The Automation Opportunity Map
• The Founder's Theses