Appeal by a physician to a third-party payer for medical services not yet provided to the patient. Also see appeal, postservice appeal, and expedited appeal.

Legal assumption that a fact exists.

Assumption of total disability when an insured is considered totally disabled (blindness, loss of hearing, speech, or limbs). The insurance company may pay a lump sum in addition to monthly payments for a maximum benefit period.
***
A disability involving loss of sight, hearing, speech or any two limbs, which is presumed to be a permanent and total disability. In such cases, the insurer does not require the insured to submit to periodic medical examinations to prove continuing disability.

A federal/state program designed to ease access to prenatal care offering immediate temporary coverage to low-income women pending a formal Medi-Cal application.

Possible biological father of a child but not necessarily the legal parent or the confirmed father. Also referred to as alleged father.

Fee that is most frequently charged in an area by a specialty group of physicians. The top of this range establishes an overall limitation on the charges that a carrier, which considers prevailing charges in reimbursement, will accept as reasonable for a given service without special justification. In the Medicare program, this factor was previously used in determining payment.

Number of existing cases of a disease or condition in a defined population at a specific time. Calculation: Divide the number of persons with the disease by the total population of the defined group to obtain the prevalence rate of a disease.

Action taken to diminish the onset of disease or an injury such as hand washing, refrigeration of foods, no smoking, little or no alcohol intake, prenatal care, and exercise.
***
Elimination of causes of loss.

Health care that focuses on disease prevention and maintaining good health such as annual physical examinations, mammograms, Pap smears, prostate and colorectal cancer screenings, and influenza and pneumonia vaccinations. This includes early diagnosis of disease, identification of individuals who are prone to certain illnesses, counseling, immunizations, regular exercise, avoidance of smoking, prudent diet, correction of congenital anomalies, and screening programs. Also called disease prevention and health management.
***
This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur.