Professional evaluation to determine a property’s insurable value or the amount of a loss.

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An assessment to determine the value of an item or property to obtain adequate insurance coverage or determine replacement value.

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A determination of the value of property for the purposes of determining the proper amount of insurance to be bought or in adjusting a loss. In event of a loss and the carrier and insured disagree on the amount of the loss, either may request an appraisal. Each party then selects an appraiser, and the appraisers select an umpire. An agreement between two of the three determines settlement.

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Survey or examination of real or personal property to determine its value. In real estate transactions, the appraisal normally measures the market value of the property. In Insurance, appraisals normally measure the actual cash value, replacement cost, or other insurable value of property. Refer “Value, actual cash value,” and “Replacement Cost.”

Term used by some health plans to define the proper setting of medical care for which the expected health benefits exceeds the expected negative outcome by sufficient margin to justify treatment. Also referred to as appropriateness of care .

Nineteen criteria for admission under the prospective payment system, separated into two categories: severity of illness and intensity of illness. To allow a patient admission to an acute care facility, one criterion from each category must be met.

Blue Cross and Blue Shield phrase that means the formal notice sent by a host plan from the home plan after the home plan has received the admission wire and verified membership information. This approval is given for a specific number of days and insurance contract benefits. See also admission wire.

1. Maximum dollar value the commercial private insurance company or managed care contract assigns to each procedure or service on which payment is based. Typically, a percent (e.g., 80%) of the allowed amount is paid by the insurance carrier. 2. Allowed amount based on the Medicare fee schedule or its transition rules, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the difference. Nonparticipating physician charges are subject to the limiting charge. 3. Also called the allowed amount or approved amount. See also Medicare-approved amount, maximum allowable, and maximum allowable charge (MAC).

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Amounts paid under health insurance as the maximum fee for a covered service.

1. Medical facility authorized to provide medical services and specific health care services stated in managed care contracts. 2. Hospital authorized to treat and admit beneficiaries of the Medicare program. Also known as approved health care hospital .