Calculation to determine the reasonable cost incurred by individual providers when furnishing covered services to beneficiaries. Reasonable cost is based on the actual cost of providing such services including direct and indirect costs of providers, excluding any costs that are unnecessary in the efficient delivery of services covered by a health insurance program.

System used by Medicare fiscal intermediaries under established guidelines from the Centers for Medicare and Medicaid Services (CMS) to find the reasonable cost incurred by the provider when rendering services to a Medicare patient. These guidelines try to exclude unnecessary medical costs.

Amount on which payment is based for participating physicians in the Medicare program; a charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailing criteria. This would include unusual circumstances or complications requiring additional time, skill, or experience in connection with a particular service or procedure.

Legal phase used when proving the cause of an injury that means the injury was more likely than not caused by a certain agent or factor.

Permission to extend an inpatient hospital stay beyond the number of days originally approved.

To send another request for payment for an overdue bill to either the insurance company or patient.

Procedure by an insurance company to regroup medical services that have been billed erroneously under different codes.

In workers’ compensation, this legal phrase exists for each case meaning that specific conditions are work related for certain groups of workers; thus the employer must prove the condition was not caused by work or the injury will be compensable.