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Definitions (81)
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adjudication
Process used by insurance companies to determine the payment amount for a claim.
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allergy treatment
Testing and evaluations to determine the existence of an allergy, including allergy and serum injections.
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allowable charge
The maximum fee an insurance company will reimburse a provider for a given service.
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ambulatory surgery
Surgical procedures that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called "Outpatient Surgery."
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ambulatory services
Services provided to a member who can walk and is not confined to a bed. Generally applies to same-day or outpatient procedures.
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appeals
Processes used by a member to request the insurance company re-consider a previous denial of authorization-- or claim decision.
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authorization
See "Preauthorization." Also known as "Precertification." B Benefit: Payments provided for covered services under the terms of the health benefit plan. The benefits may be paid to the insured, or on his/her behalf, to the medical provider.
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benefit period
The maximum length of time for which benefits will be paid.
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brand name drug
A patented prescription drug available only through the manufacturer. C Case Management: A program that assists the member in determining the most appropriate and cost effective treatment plan. Case management is usually provided to members who have prolonged, expensive or chronic conditions. The program helps determine the treatment location (hosp [..]
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