Medical or surgical procedure that may be obsolete or of doubtful value. Such procedures or tests are usually marked to be manually reviewed by a managed care plan’s utilization review committee for appropriateness of care.

Insurance claim held by the insurance carrier as pending either due to an error or the need for additional information.

1. Processed insurance claim held as pending either due to an error or the need for additional information. 2. Reminder method used to track pending or resubmitted insurance claims and to telephone or send inquiries about nonpayment. Also called a follow-up file, tickler file , or tracing file . Also see tracing file or tickler file .

Time span or hold period following discharge of a hospitalized patient in which the patient’s financial account remains available for charges and services before it drops into the claim-submission queue. Once this period passes, the account is deemed “unbilled.” This hold period is established by the hospital’s finance department.

Preparation of a liquid drug in which the particles are undissolved and must be mixed by stirring or shaking before administration.

Withholding of payment by a fiscal intermediary or insurance carrier from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists. Also called managed care payment suspension .

System for establishing goals for the rate of growth in expenditures for physicians’ services.