Iisiseko zeNtlawulo yezoNyango

Oko Kufuneka Ukwazi Xa Uhlola Imisebenzi Yomzimba Wonyango

Iibhilizi zonyango zijongene nokufakwa ngexesha elifanelekileyo ngexesha leemfuno zezobugcisa okanye zezonyango kwiinkampani zomshuwalense kubandakanywa iiofisi zonyango, izibhedlele, amakhaya angamahlengikazi, okanye ezinye izibonelelo zonyango. Kwimeko yesibhedlele , iibhilikhi zezokwelapha zenza imisebenzi eyahlukeneyo kunezibhengezo zonyango ezisebenza kwezinye izicwangciso.

Ukuba unomdla wokuba ngumgqirha wezonyango, nantsi iisiseko malunga nenkqubo yokuhlawula ngonyango, abahlawuli abaziintloko kunye nendlela yokwenziwa ngayo.

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Izicwangciso ze-inshurensi zezempilo

Ukuqonda izicwangciso ze-inshorensi zempilo kwenza abasebenzi basebefesini bonyango bakwazi ukunxibelelana ngokufanelekileyo nezigulane malunga neentlawulo ze-inshorensi zezempilo kwaye baxoxe ngeenkcukacha zegulane ze-akhawunti kunye nabameli be-inshorensi.

Ukuba nolwazi olusisiseko lwaluhlobo ngalunye lwe-inshorensi luyakunciphisa ubunzima bokufaka izicelo zamabango kunye nokuqokelela iintlawulo. Kukho iintlobo ezimbini ezibalulekileyo ze-inshorensi yezempilo:

1. Inkonzo yomshuwalense: Iiprogram-ntlawulo zeenkonzo
2. IziCwangciso zokuNakekela
   • Imibutho yezoMpilo (ii-HMO)
   • Imibutho yabanikezeli abathandayo (ii-PPOs)
   • Imibutho yeeNkonzo eziPhambili (i-EPOs)
   • Izicwangciso ze-Point-of-Service (POS)

Kaninzi

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Iinkqubo zoNonophelo lwezeMpilo zikaRhulumente

Ndiyicacise : I-Medicare yinkqubo yesigqeba esinika inkxaso yokunakekelwa kwempilo kuma-Amerika angaphezu kwezigidi ezingama-40 eziquka:

• asebekhulile ngaphezu kweminyaka engama-65 ubudala
• abakhubazekileyo ngokusisigxina abantu abangaphantsi kweminyaka engama-65 ubudala
• abantu abachaphazelekayo kwi-End-Stage Renal Disease (ESRD) esona sigxina esingapheliyo sezintso esifuna i-dialysis okanye i-kidney transplant

Uxilongo : Kubalulekile ukugcina engqondweni ukuba iMedicaid ayikho umshwalense. I-Medicaid yinkqubo eyenza iintlawulo zonyango egameni lommkeli.

Ukuba ngaba umntu ohlala esithathu unomthwalo, ngoko uMedicaid uhlala ehlawula umvuzo wokugqibela. Oku kuthetha ukuba iMedicaid ihlala ihlawula ngokugqibela apho kukho enye inshurensi.

I-TRICARE: I- TRICARE, inxalenye yeNkqubo yezeMpilo yaseMpi eqhutywe yiSebe lezoKhuseleko (iDoD), yinkqubo yononophelo lwempilo yabasebenzi benkonzo abakhulayo, abahlala phantsi kunye nabaLondolozi kunye neentsapho zabo.

I-CHAMPVA: Nangona efana ne-TRICARE, i-CHAMPVA iphathwa yiSebe leMantloko, kwaye ukuba ilungu lifanelekile kwi-TRICARE abayikwazi ukufaneleka yi-CHAMPVA. Zombili i-TRICARE kunye ne-CHAMPVA zihlala zisekondari kwezinye izicwangciso ze-inshurensi yezempilo ngaphandle kwezicwangciso ezongezelelweyo kunye neMedicaid.

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Inkqubo yoTywala yeMpilo

Ingxelo yokungena ngesifo: Ngethuba lokungenwa kwesigulane, ulwazi lwemibala yesigulane lufakiwe kuquka umhlawuli-mali, inombolo yomgaqo-nkqubo kunye nolunye ulwazi oluyimfuneko ukulungiselela ibango elihlambulukileyo.

Uqinisekiso lwe-inshorensi kunye nokuqinisekisa: Ngenxa yokuba iinkcukacha ze-inshorensi zingatshintsha naliphi na ixesha, kwanezigulane eziqhelekileyo, kubalulekile ukuba umboneleli aqinisekise ukuba ilungu ngalinye liyafaneleka. Le nyathelo yenkqubo nayo iyimfuneko ukufumana inzuzo kunye nolwazi lokugunyaziswa.

Ukungena kweNtlawulo: Ukungeniswa kwefowuni ukungena kweentlawulo zeenkonzo ezifunyenwe ngumguli kwaye kubandakanya ukudibanisa okufanelekileyo kwiikhowudi zezokwelapha kwiinkonzo kunye neenkqubo ezenziwe ngexesha lokutyelela isiguli.

Ukubhalwa kweenkcukacha zokuxilongwa, iinkqubo, kunye ne-modifiers : Amabango okuqamba ngokuchanekileyo avumela ukuba umntu ohlawula i-inshorensi awazi ukugula okanye ukulimala kwesigulane kunye nendlela yokonyango.

Ukungeniswa kwamabango : Emva kokuba ibango lizalisekile, ibango li ngeniswe ngenkokhelo kumhlawuli-bhorensi. Ukuze kufake izicelo zamabango ogqirha ngokufanelekileyo, iibhaski zonyango kufuneka zikwazi okanye zifumane ulwazi oluninzi kwinkampani nganye yomshuwalense.

Ukuhlawulwa kweentlawulo: Ukuthunyelwa kweentlawulo kubandakanya ukuthumela nokufaka idiphozi imisebenzi kunye nokuxolelana kwemisebenzi yokuthumela kunye neentlawulo.

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Uhlawulo lweeNgxowa-mali kunye neYilwayo yeZiko

Kwintlawulo yezobugqirha, kukho ezimbini iintlobo ezahlukeneyo zokuhlawula - ukuhlawula ubuchwepheshe kunye nokuhlawula iziko.

Uhlawulo lwezakhono: Uhlawulo lwezobugcisa lujongene nokuhlawula amabango awenzelwe umsebenzi owenziwa ngabagqirha, ababoneleli kunye nabanikezeli bamaziko abangenabaniki bezikolo kunye nezibonelelo zonyango. Iindleko zengcali zihlawulwa kwifom ye-CMS-1500. I-CMS-1500 iyinki ebomvu kwifom yefom yephepha elimhlophe elisetyenziswe ngamagqirha kunye nababoneleli ngebango lokubakho.

Uhlawulo lwamaziko: Ukuhlawula i- Institutional inoxanduva lokuhlawula amabango awenzelwe umsebenzi owenziwe zizibhedlele, amaziko anesiko esinonophelo, kunye namanye amaziko ezinkonzo zonyango kunye nezigulane eziquka ukusetyenziswa kwezixhobo nokubonelela, iinkonzo zelabhoratri, iinkonzo ze-radiology kunye nezinye iintlawulo. Iintlawulo zeziko zihlawulwa kwi-UB-04. I-UB-04 iyinki ebomvu kumfaki omhlophe wefom yefom yesicelo esetyenziswe ngababoneleli bamaziko ekuhlawula ibango.

Kaninzi

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Uhlawulo lweeNkcazo zeMali kunye nePhepha leMatyala

Iphepha lokuhlawula akulolo lokuqala lokukhetha amabango ezonyango kodwa ngezinye izihlandlo eziyimfuneko. Kakade, inkqubo yebango le-electronics ilula kakhulu kwaye ikhawuleza xa kuthelekiswa nenkqubo yokubhaliweyo yokuhlawula iphepha.

Uninzi lwabahlawuli be- inshorensi enkulu banika ukufakwa kwebango le-elektroniki. Unokuzikhethela ukuhlawula ngokuthe ngqo okanye ukuseta i-akhawunti kunye nendawo yokucoca.

Indlu yokuhlanza yinkampani eya kwamkela onke amabango akho kunye nekhompyutheni ngokuyithumela kubakhokheli bomshuwalense ukulungiselela. Baye bahlela endaweni ukuze bahlole iimpazamo kwibango lakho ukuze bancede ukuphepha ukulibaziseka kwintlawulo.

Inzuzo enkulu yokuhlawulwa kwekhompyutheni ingaba usebenzisa i-clearinghouse okanye u-oya kubhalwa i-bill ukuba uya kukhawuleza ukuqhubela ibango lakho. Iphepha lokuhlawula lingathatha iintsuku ezingama-45 ukulungiselela.

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Ofisi yezoNyango

Uya kufuna ukujwayelana nale miqathango enxulumene ne-inshurensi yempilo, ukuhlawulwa kwezokwelapha, ukukhokhwa kwezokwelapha, iteknoloji yentlawulo, kunye ne-teknoloji yolwazi lwezempilo.

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UkuLawulwa kweeMangalo zonyango

Uya kufuneka ukuqonda amabango e-elektroniki kunye neenguqu zeekhompyutheni zeefom, ezifunyenwe yi-Medicare, Medicaid, kunye neenkampani ezininzi ze-inshorensi. Nangona kunjalo, amabango okuhlawula i-paper ayenakho kwaye uya kufuneka ukuba ujwayelane ekusebenzeni.

Kaninzi

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Uhlawulo lwezoNyango kwi-Medicare, Medicaid, kunye neTricare

Abahlawuli ba rhu lumente bayingxenye ebalulekileyo yokuhlawula ngonyango. Uya kufuneka ukuba uqhelane kakuhle neenkqubo zazo. Hlola ngamnye ngokubanzi, kunye nezinye zeenkampani zomshuwalense yabucala.

Kaninzi