Insurance policy provision under coordination of benefits that defines any medically necessary, reasonable, or customary item of expense and is a benefit of one or more of the insurance plans under which an individual is insured.

Maximum dollar value the insurance company assigns to each procedure or service on which payment is based. Typically, a percent (e.g., 80%) of the allowed amount is paid by the insurance carrier. Also called approved charge or approved amount. See also maximum allowable and maximum allowable charge (MAC).

Individual charge determined by an insurance carrier for a covered supplemental medical insurance (SMI) medical service or supply.

In workers’ compensation cases, a condition recognized as a direct result of an industrial injury or occupational illness.

In the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code book, an alpha list of diagnoses located in Volume 2. This assists in trying to choose an accurate diagnostic code for a medical case.

In the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code book, an alpha list of causes and places of injuries and poisoning, located at the back of Volume 2. This assists in trying to choose an accurate diagnostic code for an injury or poisoning case.

Unethical and illegal practice of changing or adding an amendment to a patient’s medical records either to obtain more reimbursement or due to a pending audit or legal review of records.

Individual entitled to the proceeds of a life insurance policy if no primary beneficiary is living when the insured dies. Also called contingent beneficiary, secondary beneficiary, or successor beneficiary.

1. Any health care delivery system other than traditional fee-for-service (e.g., health maintenance organization [HMO], preferred provider organization [PPO], individual practice association [IPA]). 2. Provision of health services in settings that are more cost effective than an inpatient, acute-care hospital such as skilled and intermediate nursing facilities, hospice program, and in-home services.