Type of insurance claim adjudication (settlement) in which the insurance company authorizes the policyholder (insured) to settle claims and to issue payment on behalf of the insurer.

Archaic term for any X12 standard that has been approved since the most recent release of X12 American National Standards. The current equivalent term is X12 standard.

Ability of an individual to put on and take off all garments and medically necessary braces or artificial limbs, if worn. Also see activities of daily living (ADLs) .

Diagnosis-related group categories that are used by hospital facilities on discharge billing.

Computer software program that assigns diagnosis-related groups (DRGs) by abstracting data (i.e., patient’s age, sex, principal diagnosis, principal procedures performed, and discharge status) to assign appropriate DRGs to discharged patients.

Reimbursement amount a hospital receives for a Medicare patient who is assigned to a diagnosis-related group (DRG) that considers the wage rates in the hospital’s region and the cost related to the DRG.

Index number that reflects the resource spending associated with each diagnosis-related group.

Insurance underwriting phrase for evidence of alcohol abuse or alcoholism.

List of prescribed drugs recommended by a managed care plan and dispensed by participating pharmacies to members of the plan. It is periodically reviewed and modified. See the three types—open, closed, and restricted formularies for information. See formulary .
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A schedule of prescription drugs approved for use which will be covered by the Health Insurance Plan of the insurer and dispensed through participating pharmacies.