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.
Helping the people you serve
If you work at a library, an Area Agency on Aging, a senior center, a SHIP, a community health center or a veterans organization, the most useful thing here is probably the free materials you can print and hand out — posters, a costs card and checklists, in English, Spanish, Chinese and Vietnamese. Print them, copy them, add your own logo. No cost, no registration.
You can also put our free sign-up date calculator directly on your own website, and point people to this site in whichever of those languages they read.
Everything below is reference material for staff who need the mechanics: how appeals work, what plans must cover, how billing and networks operate.
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.