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Amount a physician or other practitioner charges for a particular medical service or procedure. The actual charge may differ from the allowed charges under insurance programs.
A technique of oriental medicine performed only by licensed health care providers. Fine needles are inserted into the body at specific points to induce anesthesia, relieve pain or to treat other various disorders.
The process used by health plans to determine the amount of payment for a claim.
Formal acceptance as an inpatient by an institution, hospital or health care facility.
Aggregate/Unstacked Out-of-Pocket Maximum
Applies to families only: the family out-of-pocket maximum must be met before any member’s services will be covered at 100 percent up to the Allowed Benefit. The out-of-pocket maximum dollar amount may be met by one member or any combination of members.
Physician directed medical treatment for allergies, which may include testing and the administration of serum through injections.
The maximum dollar amount allowed for services covered, regardless of the provider's actual charge. A provider who participates in a network cannot charge the member more than this amount for any covered service.
A procedure code in the Alternate Procedure field that indicates the procedure code to be used in the calculation of benefits in place of the procedure code actually submitted on the claim.
Benefits available for health care services received when a covered person is not confined to a hospital bed as an inpatient. Examples include outpatient care, emergency room care, home health care and pre-admission testing.
A wide range of health care services, including preventive care, acute care, surgery and outpatient care, in a medical care facility. Services do not require an overnight hospital stay.
Surgery which does not require an inpatient hospital admission for convalescence or recuperation. May also be referred to as one-day, same-day or outpatient surgery.
Hospital services other than bed, board and nursing care. Examples include drugs, dressings, operating room services, special diets, radiology, laboratory examinations, anesthesia and medications. Ancillary may include inpatient ancillary services, but also commonly includes services provided by ancillary providers in the home or outpatient setting (i.e., free-standing ambulatory surgical facility, radiology, laboratory and/or home health care).
A process used by a patient or provider to request the health plan to reconsider a claim decision.
The provider has agreed to accept Medicare's allowed amount as payment-in-full for the service rendered. The provider may not balance bill for these services. This amount may be reduced by specific coinsurance and deductible amounts to be paid by the member.
Physician primarily responsible for the care of a patient in a health care setting (e.g. during hospitalization).