Okuyisisekelo Sokukhokhiswa Kwezokwelapha

Okudingeka Ukwazi Uma Uhlola Imisebenzi Yomsebenzi Wezokwelapha

Abathengisi bezokwelapha banesibopho sokuhambisa okwesikhashana izicelo zezobuchwepheshe noma zezokwelapha ezinkampanini zomshuwalense kubandakanya amahhovisi odokotela, izibhedlela, amakhaya asebekhulile, noma ezinye izikhungo zezempilo. Esendaweni yesibhedlela , izikhwama zezokwelapha zenza imisebenzi ehlukene kunezikhwama zezokwelapha ezisebenza kwezinye izilungiselelo.

Uma unesithakazelo sokuba ngumthengisi wezokwelapha, nansi izinto eziyisisekelo mayelana nenqubo yokukhokhiswa kwezokwelapha, abakhokhelwayo abakhulu, nokuthi kwenziwa kanjani.

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Izinhlelo Zomshuwalense Wezempilo Eziyisisekelo

Ukuqonda okuyisisekelo kwezinhlelo zomshuwalense wezempilo kwenza abasebenzi basehhovisi bezokwelapha bakwazi ukuxhumana kahle neziguli mayelana nezinzuzo zabo zomshuwalense wezempilo futhi baxoxe ngemininingwane ye-akhawunti yesiguli nabamele inkampani yomshuwalense.

Ukuba nokuqonda okuyisisekelo kohlobo ngalunye lomshwalense kuzonciphisa izinkinga zokufaka izimangalo nokuqoqa izinkokhelo. Kunezinhlobo ezimbili ezinkulu zezinhlelo zomshuwalense wezempilo:

1. Umshuwalense Wesikweletu: izinhlelo zokukhokhela izinkonzo
2. Izinhlelo Zokunakekelwa Eziphethwe
   • Izinhlangano Zokulondoloza Impilo (ama-HMO)
   • Izinhlangano Zokuhlinzeka Ezikhethiwe (ama-PPOs)
   • Izinhlangano Ezihlinzeka Ngaphandle (EPOs)
   • Izinhlelo zePoint-of-Service (POS)

Okuningi

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Izinhlelo Zokunakekela Impilo Kahulumeni

Ngikhuluma : I-Medicare yilona uhlelo lwama-federal olunikeza ukunakekelwa kwezempilo kwabaningi baseMelika abangaphezu kwezigidi ezingama-40 okubandakanya:

• asebekhulile abangaphezu kweminyaka engama-65 ubudala
• abadala abakhubazekile uneminyaka engaphansi kwengu-65 ubudala
• abantu abahlukunyezwa yi-End-Stage Renal Disease (ESRD) okuyinto yokuhluleka kwezinso ezingapheli ezidinga i-dialysis noma ukufakelwa kwezinso

I-Medicaid : Kubalulekile ukukhumbula ukuthi iMedicaid ayiyona inshuwalense. I-Medicaid uhlelo olwenza izinkokhelo zezokwelapha egameni lomamukeli.

Uma ngabe icala lesithathu likhona, khona-ke iMedicaid ihlala njalo ikhokha yokusebenzisa okugcina. Lokhu kusho ukuthi iMedicaid ihlale ikhokha ekugcineni lapho kukhona khona umshuwalense.

I-TRICARE: I- TRICARE, ingxenye ye-Military Health System eqhutshwa nguMnyango Wezokuvikela (DoD), uhlelo lokunakekelwa kwezempilo lwabantu abasebenza ngokuhlala, abahlala emhlalaphansi kanye nabalindi nabasebenzi babo.

I-CHAMPVA: Nakuba ifana ne-TRICARE, i-CHAMPVA iphathwa yi-Department of Veterans Affairs, futhi uma ilungu lifaneleka ku-TRICARE ngeke likwazi ukufaneleka yi-CHAMPVA. Kokubili i-TRICARE ne-CHAMPVA bahlale beya eminye imikhakha eminye imikhakha ye-Insurance Health ngaphandle kwamacebo okungeziwe kanye neMedicaid.

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Inqubo Yokukhokhiswa Kwezokwelapha

Ukungena ngesineke : Ngesikhathi sokuhlolwa kwesiguli, ulwazi lomuntu wesiguli lufakiwe kufaka phakathi umkhokheli womshuwalense, inombolo yenqubomgomo, nolunye ulwazi oludingekayo ukuze kusetshenzwe isimangalo esihlanzekile.

Ukufaneleka komshuwalense nokuqinisekiswa: Ngoba ulwazi lomshuwalense lungashintsha nganoma isiphi isikhathi, ngisho neziguli ezivamile, kubalulekile ukuthi umhlinzeki aqinisekise ukufaneleka kwesilungu njalo izinsizakalo zinikezwa. Lesi sinyathelo senqubo futhi siyadingeka ukuthola ulwazi lokuhlomula nokugunyazwa.

Ukungena okukhokhwayo : Ukungeniswa kwemali ukungena kwezindleko zezinsizakalo ezitholwa yisiguli futhi kufaka ukuxhumanisa okufanelekile kwamakhodi wezokwelapha kumasevisi kanye nezinqubo ezenziwa ngesikhathi sokuvakashela isiguli.

Ukukhokhwa kwe-diagnostic, izinqubo, kanye nama-modifiers : Izimangalo zokukhokhwa ngokucacile zivumela ukuthi umkhokheli womshuwalense azi ukugula noma ukulimala kwesiguli kanye nendlela yokwelapha.

Ukufakwa kwezimangalo : Ngemva kokuthi isimangalo sesiphelile, isimangalo sihanjiswa ngenkokhelo kumkhokhi womshuwalense. Ukuze uthumele izimangalo zezokwelapha ngokuphumelelayo, izikhwama zezokwelapha zidinga ukwazi noma ukuthola ulwazi oluningi kwinkampani yomshuwalense ngamunye.

Ukuthunyelwa kwenkokhelo: Ukuthunyelwa kokukhokha kuhilela ukuthumela nokufaka imisebenzi nokubuyisana kwemisebenzi yokuthumela nge-deposits.

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Ukukhokhwa Okukhokhelwayo Okusemthethweni Kanye Nezinkokhelo Zomthetho

Ekukhokheni kwezokwelapha, kunezinhlobo ezimbili ezihlukene zokukhokhisa - ukukhokhiswa kochwepheshe kanye nokukhokhiswa kwezikhungo.

Ukukhokha kobuchwepheshe: Ukukhokhelwa kwezezimali kubhekene nokukhokhwa kwezimangalo ezenzelwe umsebenzi ezenziwa odokotela, abahlinzeki kanye nabanye abahlinzeki abangenazikhungo zombili iziguli neziguli zokwelapha. Amacala ochwepheshe akhokhiswa kwifomu ye-CMS-1500. I-CMS-1500 yi-inkino ebomvu ephepheni elimhlophe lefomu lezimangalo elimhlophe elisetshenziswe odokotela nabahlinzeki ngokukhokhiswa kwesicelo.

Ukukhokhwa kwezikhungo: Ukukhokhiswa kwezikhungo kubhekene nokukhokhwa kwezimangalo ezenzelwe imisebenzi eyenziwa izibhedlela, izindawo zokuhlengikaza abanekhono, kanye nezinye izikhungo zezinsizakalo zokugula neziguli ezibandakanya ukusetshenziswa kwemishini kanye nempahla, izinsiza zabasebenzi, izinsiza ze-radiology nezinye izinkokhelo. Izinkokhelo zezikhungo zikhokhiswa ku-UB-04. I-UB-04 yi-inkino ebomvu ephepheni elimhlophe lefomu lokufaka isicelo elimhlophe elisetshenziswe ngabahlinzeki bezikhungo ekukhokheni imali.

Okuningi

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Ukukhokhwa Kwezimangalo Zomthetho Wokukhokhwa Nezincwadi

Ukukhokhwa kwephepha akuyona ukukhetha kokuqala kwezindleko zezokwelapha zokukhokhisa kodwa ngezinye izikhathi umsebenzi odingekayo. Yiqiniso, inqubo yokufaka izicelo ze-elekthronikhi ilula kakhulu futhi isheshe iqhathaniswe nenqubo yezincwadi zokukhokha kwephepha.

Iningi labakhokhisi bomshuwalense abakhulu linikeza ukufakwa kwezicelo ze-elektroniki. Unayo ukukhethwa kokukhokha okuqondile noma ukusetha i-akhawunti ngendlu yokuhlanza.

Indlu yokuhlanza iyinkampani ezokwamukela zonke izimangalo zakho futhi izithumele nge-elekthronikhi kubakhokhi bomshuwalense wokucubungula. Baphinde bahlele endaweni ukuze bahlole amaphutha kwisimangalo sakho ukuze basize ukugwema ukubambezeleka ekukhokhiseni.

Inzuzo enkulu yokukhokhiswa kwe-electronic noma ngabe usebenzisa i-clearinghouse noma uyayikhokhisa yini ukuthi uzosheshisa izicelo zakho zokucubungula. Ukukhokha kwephepha kungathatha izinsuku ezingu-45 ukucutshungulwa.

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I-Term Office yezokwelapha

Uzofuna ukujwayele lawa magama ahlobene nomshuwalense wezempilo, ukukhokhiswa kwezokwelapha, ikhodi yezokwelapha, ubuchwepheshe bokukhokha, nobuchwepheshe bezokwelapha.

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Ukucubungula Izimangalo Zezokwelapha

Kuzodingeka uqonde izimangalo zekhokhthi zekhompyutha ngezinguqulo ze-elekthronikhi, ezamukelwa yi-Medicare, Medicaid, nezinkampani eziningi zomshuwalense. Noma kunjalo, izimangalo zokukhokha zamaphepha zisekhona futhi kuzodingeka uzijwayele ukuzicubungula.

Okuningi

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Ukukhokhwa Kwezokwelapha ku-Medicare, Medicaid, ne-Tricare

Laba bakhokha uhulumeni yingxenye ebalulekile yokukhokha kwezokwelapha. Uzodinga ukuba wazi kahle izinqubo zabo. Hlola ngamunye ngokujula, kanye nezinye zezinkampani ezinkulu zomshuwalense wangasese.

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