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.

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.