1. Medicare+Choice organization’s second look at whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health, or ability to regain function may be jeopardized. 2. Appeal for medical service, thought by the physician, to be urgent.

Fast decision from the Medicare+Choice organization about whether it will provide health service. A beneficiary may receive a quick determination within 72 hours if life, health, and ability to regain function may be jeopardized.

1. Issuance of checks, disbursement of cash, or electronic transfer of funds made to liquidate an expense regardless of the fiscal year the service was provided or the expense was incurred. 2. When used in the discussion of the Medicaid program, expenditures refer to funds spent as reported by the states. Also called outlay .

Maximum level of spending for the health sector or certain categories of services. It is usually established by the government through rate setting or premium limits.

Statistical examination of insurance experience for any part of the group business such as a line or a territory; any group of cases, coverages, or benefits; or any single case, coverage, or benefit. The study may include single or multiple experience periods, past and future trends, and various descriptive statistics.

Time period of usually 12 months in which premium and insurance claim records are gathered for a rate review. Also referred to as a review period .

Insurance premium based on the experience rating. This is periodically adjusted in line with actual insurance claims or utilization experience.

Insurance premium rates for group insurance coverage based, wholly or partially, on the past claims of the group.

Any treatment, procedure, equipment, drug, drug usage, device, or supply not generally accepted as standard care in the practice of medicine. This includes services or supplies requiring federal or government approval not granted at the time services were rendered. Also called investigative . See experimental care .