US Healthcare Administration 📞 Book a 1:1

00 Start Here

Glossary & Acronyms Home How to Use This Map The 90-Second Mental Model

01 The Stakeholders

ACA Marketplace Plans Brokers, Consultants & Benefits Advisors Clearinghouses Commercial & Employer-Sponsored Insurance Dual Eligibles & D-SNPs Group Purchasing Organizations (GPOs)🔒 Independent Review Organizations (IROs)Industry Trade Associations & Lobbying Medicaid & Managed Medicaid Medicare Medicare Advantage Members & Patients 🔒 Payers (Health Plans)Physician Groups, IPAs & Medical Groups Post-Acute & Long-Term Care Providers & Health Systems Regulators & Oversight Bodies Self-Funded Plans & ASO Specialty Benefit Managers 🔒 The Member Digital Front Door The Stakeholders 🔒 Third Party Administrators (TPAs)TRICARE & VA Health

02 How Money Flows

Coordination of Benefits & Subrogation Cost Sharing Denials Management & Remittance Codes (CARC, RARC)DRGs & Prospective Payment Systems EDI & X12 Transaction Standards 🔒 Encounter Data Submission (EDPS, RAPS & State Encounters)Fee Schedules & Allowed Amounts How Money Flows Medical Debt & Hospital Collections Medical Loss Ratio (MLR)Price Transparency & Good Faith Estimates Real-Time Eligibility & Benefits Verification Reimbursement Models Revenue Cycle Management (RCM)Risk Adjustment & HCC Coding The Claims Lifecycle The Premium Dollar

03 Coverage & Benefits

Benefit Design & the SBC Coverage & Benefits Eligibility & Enrollment EMTALA & Emergency Care Coverage EPSDT — Medicaid's Child & Adolescent Benefit Essential Health Benefits & State Mandates Experimental & Investigational Coverage Medical Policy & Coverage Determinations Plan Types (HMO, PPO, EPO, POS, HDHP)🔒 Prior Authorization Provider Networks

04 Utilization Management

Appeals & Grievances Behavioral Health Review 🔒 Clinical Criteria (MCG & InterQual)Concurrent Review 🔒 Determination & Notification Letters Diagnostic Imaging & Testing Review Durable Medical Equipment (DME) Review 🔒 Gold-Carding & Auto-Approval 🔒 Information Requests & RFI Templates 🔒 Inpatient Admissions Review 🔒 Inter-Rater Reliability (IRR)Local & National Coverage Determinations (LCD & NCD)🔒 Medical Necessity Member Notices in Utilization Management 🔒 Outpatient & Ambulatory Review 🔒 Peer-to-Peer Review Post-Acute Care Review 🔒 Precertification Lists & CPT Mapping 🔒 Retrospective Utilization Review 🔒 Site-of-Care & Site-of-Service Steering Specialty Drugs & Infusion Review 🔒 The Prior Authorization Workflow 🔒 The Utilization Management Team Turnaround Time & Regulatory Clocks 🔒 UM Operational Metrics, Staffing & Productivity 🔒 Utilization Management 🔒 Utilization Management by Service Line 🔒 Utilization Review

05 Care Management & Population Health

Behavioral Health Management & Parity Care Gaps & SDOH Care Management & Population Health Care Navigation & Advocacy Case Management Disease & Chronic Care Management Maternity Care Management 🔒 Medicaid LTSS & Home- and Community-Based Services Population Health Management Remote Monitoring & Digital Health Programs Telehealth & Virtual Care Transitions of Care & the Readmissions Reduction Program

06 Clinical Data, Coding & Interoperability

Clinical Data, Coding & Interoperability Clinical Documentation Integrity (CDI)EHRs & the Provider Tech Stack Healthcare Cybersecurity & Operational Resilience HL7, FHIR & USCDI Information Blocking & the Cures Act Medical Coding Systems Modifiers & Place-of-Service Coding SMART on FHIR & EHR Apps TEFCA & Health Information Exchange The Da Vinci Project (CRD, DTR, PAS)

07 Payment & Program Integrity

Claims Editing & the NCCI (Correct Coding Edits)DRG Validation & Clinical Validation Fraud, Waste & Abuse (FWA) & the SIU Itemized Bill Review 🔒 OIG Enforcement: Exclusions, CIAs & Civil Monetary Penalties Overpayment Recovery, COB & Subrogation Payment & Program Integrity 🔒 Payment Integrity Pre-Pay vs Post-Pay Review Retrospective Claim Review

08 Pharmacy & PBMs

340B Drug Pricing 🔒 Cell, Gene & One-Time Therapy Financing Formularies, Rebates & the Drug Supply Chain 🔒 GLP-1 & Anti-Obesity Medication Management Medicare Part D Medication Adherence, DUR & Medication Therapy Management Pharmacy & PBMs Pharmacy Benefit Managers (PBMs)Pharmacy Prior Authorization & Step Therapy Specialty Pharmacy

09 Value-Based Care & Risk

Accountable Care Organizations (ACOs)Bundled & Episode-Based Payments 🔒 Capitation, Full-Risk & Delegated Risk Fee-for-Service vs Value-Based Care Quality Measurement (HEDIS, Stars, MIPS)Stop-Loss Insurance & Reinsurance Value-Based Care & Risk

10 Regulation & Policy

42 CFR Part 2 — SUD Record Confidentiality 🔒 Accreditation (NCQA & URAC)CMS (Centers for Medicare & Medicaid Services)🔒 Delegation Oversight & FDR Management ERISA & Self-Funded Plans HIPAA 🔒 Medicare Advantage Oversight, Audits & Marketing Rules Mental Health Parity (MHPAEA)Prior Authorization Data & Public Reporting Regulation & Policy Section 1557, Language Access & Health Equity Stark Law & the Anti-Kickback Statute State Regulation & Departments of Insurance The Affordable Care Act (ACA)The CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F)The Healthcare Compliance Program The No Surprises Act

11 The Vendor Landscape

Care Management Platforms Clinical Criteria & Content Vendors Core Administrative Processing Systems 🔒 Health-IT Investors, Private Equity & Strategic Acquirers Payment Integrity Vendors Prior Authorization Vendors Provider Data & Credentialing Vendors 🔒 System Integrators, Consultancies & Clinical BPOs 🔒 The AI & Automation Entrants The Health-IT Vendor Map The Vendor Landscape 🔒 Utilization Management Platforms 🔒 Value-Based Care Enabler Companies

12 Where It Breaks & Where AI Wins

🔒 AI Governance & Model Risk in Healthcare Administration Building & Selling Healthtech (Go-to-Market)🔒 The Automation Opportunity Map 🔒 The Cost of Administrative Complexity The Founder's Theses 🔒 The Prior Authorization Problem 🔒 The Provider-Payer AI Arms Race 🔒 The Startup Opportunity Index 🔒 What Breaks in Utilization Management Today 🔒 Where It Breaks & Where AI Wins 🔒 Who Has the Right to Win Why Prior Authorization Exists

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The Prior Authorization Workflow

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Linked from

Clinical Criteria (MCG & InterQual)
Diagnostic Imaging & Testing Review
ERISA & Self-Funded Plans
Eligibility & Enrollment
Gold-Carding & Auto-Approval
How to Use This Map
Information Blocking & the Cures Act
Information Requests & RFI Templates
Medical Policy & Coverage Determinations
Members & Patients
Outpatient & Ambulatory Review
Payment Integrity
Peer-to-Peer Review
Pharmacy Prior Authorization & Step Therapy
Plan Types (HMO, PPO, EPO, POS, HDHP)
Precertification Lists & CPT Mapping
Prior Authorization
Prior Authorization Vendors
Retrospective Utilization Review
SMART on FHIR & EHR Apps
Specialty Benefit Managers
State Regulation & Departments of Insurance
The AI & Automation Entrants
The Automation Opportunity Map
The CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F)
The Cost of Administrative Complexity
The Da Vinci Project (CRD, DTR, PAS)
The Premium Dollar
The Prior Authorization Problem
The Provider-Payer AI Arms Race
The Startup Opportunity Index
The Utilization Management Team
Turnaround Time & Regulatory Clocks
Utilization Management
Utilization Management Platforms
What Breaks in Utilization Management Today

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