In workers’ compensation, change in a preexisting condition that causes a temporary or permanent increase in disability or creates a need for additional or different medical treatment. An aggravation may be caused by either a new injury or by work activity involving a physical, chemical, or biological factor.

In a managed care contract, the maximum amount (limit) for which a member is insured for any single event.

A maximum dollar amount which may be collected for any disability, period of disability, or under the policy.******Maximum amount for which an insured may collect for any disability, period of disability, or covered medical service under an insurance policy.******The maximum amount that may be claimed during a certain period or under the policy.
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The maximum amount that may be collected for any disability or period of disability under the policy.

Agreement in a managed care plan to relieve the amount of liability for insurance claims that are in excess of the amount anticipated for the contract year. Also see stop loss.

Insurance coverage that becomes effective when an employer who has self-insurance has its total group medical insurance claims reach a specific threshold chosen by the employer. This threshold is a percentage of its yearly predicted group health claim costs.

Under a system developed by Johns Hopkins University called adjusted clinical groups (ACGs) , ACGs are a comprehensive family of measurement tools designed to help explain and predict how health care resources are delivered and consumed. ACGs are based on building blocks called aggregated diagnosis groups (ADGs). ADGs are a grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence of the health condition over time. There are two categories of ADGs, ambulatory diagnostic groups–major diagnostic category (ADG-MDC) and ambulatory diagnostic groups–hospital dominant (ADG-HosDom).

Document used to determine outstanding balances from each patient’s account showing status of 30, 60, 90, or 120 days from the date of insurance claim submission. It can be generated by using the date an insurance claim was filed to assess the age of the claim in days. Sometimes referred to as an aging report.

1. Document that reports the status of insurance claims to the provider of the medical services and identifies individual transactions that need to be followed up (e.g., appeal or resubmit a corrected a claim). 2. See aging accounts receivable (A/R) report.

Physician who is certified by the Industrial Medical Council (IMC) and conducts medicolegal evaluations of injured workers in workers’ compensation cases for insurance companies or workers’ compensation appeals board. AMEs are agreed on by the employer and a referee (represents the employee) or appeals board at the expense of one of the parties to resolve disputed medical issues. The AME is referred by the parties in a workers’ compensation proceeding. The report of an AME is considered the evidence of both parties. The AME renders an unbiased opinion about the degree of disability of an injured worker. May be referred to as independent medical evaluator (IME) or qualified medical evaluator (QME).

Legal document signed by two or more individuals that contains specific mutual understandings.

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A legal contract.