Greatest dollar amount of insurance claims payment for which an insurance company is responsible.

Health insurance policy provision that states the greatest dollar amount paid for the daily inpatient hospital room rate.

Under HIPAA, necessary data elements for a particular standard based on a certain implementation specification. The sender who creates the transaction may include whatever data the receiver might require. The receiver of the data may ignore any part of the data that is not necessary to carry on its portion of the business transaction unless some unnecessary data are necessary for coordination of benefits with another insurance company.

Medicare beneficiary’s highest dollar liability amount (copayments, deductibles, and coinsurance) for a specified time period.

Third-party reimbursement arrangement in which a participating provider agrees to accept the contract’s schedule of allowances as the total fee for each covered health care service rendered.

Total amount a health insurance plan will pay for medical care for any individual insured.

In workers’ compensation, the point of greatest recovery after all treatment has been used within a reasonable time period to allow for optimal recovery and other physiological adjustments to occur. Also see permanent and stationary (P & S) .
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US: Maximum Medical Improvement (MMI) is a treatment plateau in each person’s healing process. It can mean that the patient has fully recovered from the injury or that the patient’s medical condition has stabilized to the point that no major medical or emotional change can be expected in the injured workers’ condition. This occurs despite continuing medical treatment or rehabilitative programs the injured worker partakes in.

In workers’ compensation disability rating, it is a measurement of long-term impairment often expressed as a percentage of total body function.

Limit on the total medical expenses (number of copayments, deductibles, and coinsurance) that an insured must pay that are not covered under a managed care contract.

Highest dollar amount per time period that a plan will insure. This is only applicable for service categories where there are enhanced benefits being offered by the plan because Medicare coverage does not allow a maximum plan benefit coverage expenditure limit.