The same programs look different depending on where you sit. A prior authorization is a workflow to a health-plan analyst, a submission to a provider's biller, a talking point to an advisor, and a barrier to remove for a case manager. Pick your lane below — each page is educational reference, not compliance, legal, or sales advice.
Choose your role
Health-Plan Operations
Prior authorization, claims adjudication, grievances and appeals, pharmacy and formulary, networks, and member services — the operational core.
Providers & Billing
Enrollment and credentialing, eligibility verification, prior auth from the submitting side, claims, and provider appeals.
Brokers, Agents & Advisors
Licensing and certification, CMS marketing and compliance rules, Scope of Appointment, and consumer-first practices.
Case Managers & Navigators
Screening for programs, dual-eligible coordination, transitions of care, appeals support, and trusted referral tools.
Shared reference
Whichever role you're in, these general pages underpin the details:
Coverage Basics
How Medicare, Medicaid, Medicare Advantage, the Marketplace, and CHIP are funded, administered, and delivered.
How Programs Are Governed
The rulemaking cycle and where to track CMS guidance and regulatory change.
Deep-dive references
Star Ratings & Quality Measures
The 1–5 rating system, HEDIS/CAHPS/HOS, and quality bonus payments.
Claims & Coding Reference
Claim forms, code sets, EDI transactions, and the clean-claim lifecycle.