Method of cost containment that freezes physician and hospital fees to try to curtail inflation.

1. Individual who reviews services, procedures, diagnoses, fee schedules, and other data and establishes the amount for a medical service or supply. Also called repricer. 2. Software package in an insurance claims processing system, specific to certain benefits, which analyzes specific data and determines the amount for a medical service or supply. Subsequently, other criteria are applied to establish the actual allowance or payment amount. It is most often used under prospective payment systems.

Principle that is presumed to be true unless there is evidence given to disprove the presumption.

Standard premium rate recommended by state government regulators for a contributory group creditor insurance policy.

1. First time a patient seeks medical care from a provider. 2. Basic health care attention when a patient first contacts someone to care for simpler and more common illnesses and injuries. Primary care can be provided by a family practitioner, pediatrician, or internist and health professionals such as nurse practitioners or physician assistants.

Each primary care physician of a managed care plan receives a specific amount each month for each member who selects that physician as his or her primary care physician. See capitation (cap or CAP).

Managed care option under Section 1915(b) of the Social Security Act. In the Medicaid program, this lets states contract directly with primary care providers who agree to provide medical services to Medicaid recipients and authorize specialty care. In this system the state pays the primary care physician a monthly case management fee, as well as fee-for-service (FFS).

Usually a physician, physician group practice, or an entity employing or having other arrangements with such physicians, but sometimes also including nurse practitioners, nurse midwives, or physician assistants who contract to locate, coordinate, and monitor covered primary care and sometimes additional services.