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Knowledge Center

Episode 162: Workgroup Voices, The Inner Workings of Prior Authorization

June 5, 2023

Tiered benefits can have different meanings or be defined differently by payers and providers. They may interpret the data they exchange differently, as well as how that information could be applied when delivering patient care.

Both traditional and more complex benefit plan designs have been introduced into the health care landscape, creating the need for best practices and/or guidelines that will allow payers and providers to confidently exchange information without unnecessary confusion.

This paper will not address the No Surprises Act’s Good Faith Estimates and Advanced Explanation of Benefits concepts as that legislation did not intersect with the scope of the Eligibility & Benefits Inquiry & Response at the time of drafting.

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