Method used by insurance companies and managed care plans to establish their fee schedules in which three fees are considered in calculating payment: (1) The usual fee is the fee typically submitted by the physician, (2) the customary fee falls within the range of usual fees charged by providers of similar training in a geographical area, and (3) the reasonable fee meets the aforementioned criteria or is considered justifiable because of special circumstances.

Public-private coalition for reducing health care administrative costs through the standardization and electronic exchange of health care data.

Philosophical view or doctrine of ethics that the purpose of all action should be to bring about the greatest happiness for the greatest number of people and that the value of anything is determined by its utility.

Measurement of the frequency that members of a health insurance group use the services or procedures of a particular benefit plan, stated by average number of claims per insured over a specific time period.
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How much a covered group uses a particular insurance plan or program.

Program that replaced the Professional Standards Review Organization (PSRO) program. See Quality Improvement Organization (QIO) program .

Process and procedures implemented to administer the use of health care services in the hospital by evaluating quality of care and establishing appropriateness and medical necessity for services. It ensures maximum medical care resource use and helps reduce health care spending. Examples of UM are preadmission certifications, admission reviews, concurrent reviews, focused reviews, individual case management, discharge planning, retrospective reviews, provider profiling, and second surgical opinions.

Process, based on established criteria, of evaluating and controlling the medical necessity for services and providers’ use of medical care resources. Reviews are carried out by allied health personnel at predetermined times during the hospital stay to assess the need for the full facilities of an acute care hospital. In managed care systems such as an HMO, reviews are done to establish medical necessity and appropriateness or efficiency of health care services, thus curbing costs. UR is also monitored by both insurers and employers. Also called medical review, continued stay review, utilization , and management control .

Independent, nonprofit organization established in 1990 that promotes health care quality through its accreditation and certification programs. URAC offers a wide range of quality programs and services that keep pace with the rapid changes in the health care system and provide a symbol of excellence for organizations to validate their commitment to quality and accountability.

Registered nurse who evaluates medical cases for appropriateness of care and length of service and plans services required after discharge from a health facility.