Policy developed by Centers for Medicare and Medicaid Services (CMS) contractors (fiscal intermediary or carrier, affiliated contractor, provider service carrier) and used to make coverage and coding determinations. It is developed when there is an absence of national coverage policy for a service or all of the uses of a service; there is a need to interpret national coverage policy; or there is a need for local coding rules.

Difference between the allowed amount and the billed amount that is credited to an account as agreed upon in the insurance contract with the provider of service.

System of making hospital payments through a formal agreement with an insurance payer to accept for a patient or group of patients a discounted amount instead of actual fees as full payment for medical services.

Legal agreement between a provider and third-party payers such as Medicare or Medicaid to provide medical services for a predetermined fee; often used in a discounted fee arrangement. Also called purchase discount. See also disallowance.

Substance that is injected into the body, introduced via catheter, or swallowed to allow radiographic images of internal structures that would normally be difficult to see on x-ray films. Also called contrast material.

Maximum yearly contribution legally permitted to a participant’s account in a defined benefit pension plan (DBPP). This may include employer and employee contributions and forfeitures that have been reallocated from other participants’ accounts. The contribution limit is set under Section 415 of the Internal Revenue Code.

Dollar amount an employer must pay for the cost of health insurance coverage for employees or employees and dependents.

Income that results when a mutual insurance company makes more money than it needs to pay for the cost of providing insurance.