Evaluation of health care services to determine medical necessity and appropriateness of medical care during the time the services are being provided. It is done to encourage discharge of the patient from the hospital as soon as his or her medical condition no longer needs continued inpatient care. This may occur for inpatient, residential, partial hospitalization treatment, and outpatient care. The review is usually done at the time services are provided by a health care provider other than the one giving the care.
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A case management technique which allows insurers to monitor an insured’s hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date.

Wide-ranging sets of similar diseases clinically and cost comparable under the Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Categories (HCC) Model for capitated payments to managed care organizations.

Two-digit numeric code inserted in Fields 18 through 28 on the Uniform Bill (UB-04) insurance claim form to show that a condition applies and affects payment of the claim. Condition codes denote if coverage exists under another insurance, the illness or injury is employment related, the bill is an outlier, or medical necessity affects room assignment.

Insurance agreement in which the insured’s acceptance is considered uncertain during a specific time period and during which time the individual may cancel the agreement and receive a refund of the premium payments.
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Although only the Insurer can be forced to perform after the contract after the contract is effective, the Insurer can refuse to perform if the insured does not satisfy certain conditions contained in the contract. As such, Insurance contracts are conditional contracts.

Reimbursement made by Medicare for services for which a third-party (primary payer) is responsible. The provider (physician) requests payment from the Medicare Secondary Payer because a lengthy processing delay (more than 120 days) by the third-party payer is expected. The provider must agree to send a refund or request for reconsideration from Medicare within 60 days of the third-party payer’s payment.

Type of premium receipt given to the applicant on payment of the initial premium. The life insurance policy becomes effective before it is actually issued only on acceptance or approval of the application (i.e., the proposed insured is found to be insurable). Also called conditional receipt.

Circumstance in which Medicare is billed as the primary payer for a temporary period of time.

Insurance policy renewal provision that grants the insurer a limited right to refuse to renew a health insurance policy either to a stated date, at the end of a premium payment period, or at an advanced age.
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A continuation provision in health insurance under which the insurer may not cancel the policy during its term but can refuse to renew under specified circumstances.