1. Health insurance purchasing entity (public or private) that enrolls subscribers or members within a given region, collects premiums, enforces rules that manage health plans, and purchases subscribers’ or members’ insurance from participating health plans. 2. Organization or group of employers that pools resources to buy health care goods and services. Also known as a purchasing group . See consumer health alliances. 3. Formal, mutual arrangement of companies, providers, or institutions, established to further common goals.

Health care provider who is not licensed as a doctor of medicine or osteopathy (e.g., nurse practitioner, physician assistant, chiropractor, medical assistant).

Type of property insurance that may be purchased with a fire insurance policy.

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A term that has been adopted to refer to the lines of insurance that are allied with property insurance, these coverage provide protection against perils traditionally written by fire insurance policies such as sprinkler leakage, water damage and earthquake.

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Allied lines coverage is a form of insurance that is normally written with fire insurance. It covers additional perils not usually covered by the basic fire insurance policy. Examples of allied lines insurance include wind and hail insurance, vandalism and malicious mischief insurance, data processing insurance, demolition insurance, earthquake insurance, water damage insurance (but not flood), sprinkler leakage insurance, radioactive contamination insurance, and standing timber insurance. (See Extended Coverage).

Insurance policy provision in a group contract in which specific hospital and medical benefits such as x-rays, dressings, and drugs will be paid as shown in a schedule with a maximum amount payable for all such services.

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Payments in some health insurance policies for specified hospital services (x-rays, drugs, dressings, etc.) up to a maximum amount.

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A provision under which certain expenses usually miscellaneous hospital and medical charges such as X-ray, dressings, drugs etc. will be paid at a rate for each as scheduled in the provision. Usually, there is also a maximum total that will be paid for all such expenses.

Method used by insurers in which uninsurable small employers are equitably assigned among insurance companies.

Medical therapy in which a disease or abnormal condition is treated by creating an environment that is opposite to or incompatible with the disease or condition that the patient suffers. An example would be the use of antibiotic drugs given to patients to fight a disease caused by bacteria to which the drugs are antagonistic. Allopathic physicians are Doctors of Medicine (MDs).

1. In the Medicare program, the fee schedule amount for a medical service that is published annually by the Centers for Medicare and Medicaid Services (CMS). This fee is based on relative value units (RVUs) taking into consideration the physician’s work RVU, the practice expense RVU, and the malpractice insurance RVU. To bring the fees in line for the region where the physician practices and to adjust for regional overhead and malpractice costs, each of the RVUs is adjusted for each Medicare local carrier by geographic practice cost indices (GPCIs), pronounced “gypsies.” Sometimes this is called the approved charge. 2. Amount on which TRICARE figures the patient’s cost-share for covered care. This is based on 75% to 80% of the allowable charge.

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The lesser of the actual charge, the customary charge and the prevailing charge.