ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D
AD&D provides coverage for death or dismemberment resulting directly from accidental causes. Provides benefits in the event of loss of life, limbs or eyesight as a result of an accident.
ADMINISTRATIVE SERVICES ONLY (ASO)
An arrangement in which a plan hires a third party to deliver administrative services to the plan such as claims processing and billing; the plan bears the risk for claims. Common in self-funded health care plans
ADMINISTRATOR (EMPLOYEE BENEFIT PLANS)
Under ERISA, the person designated as such by the instrument under which the plan is operated. If the administrator is not so designated, administrator means the plan sponsor. If the administrator is not designated and the plan sponsor cannot be identified, the administrator may be such person as is prescribed by regulation of the Secretary of Labor. The administrator’s responsibilities are as follows: (1) act solely in the interest of plan participants and beneficiaries, and for the exclusive purpose of providing benefits and defraying reasonable administrative expenses; (2) manage the plan’s assets to minimize the risk of large losses; and (3) act in accordance with the documents governing the plan.
A form of utilization review in which assessment is made of the necessity-based on health status and treatment needs-of a patient’s admission to the hospital or other inpatient institution; health status considerations include both physical and psychological conditions.
the tendency of an individual to recognize his or her health status in selecting the option under the retirement system or insurance plan that tends to be most favorable to him or her (and more costly to the plan) In insurance usage, a person with an impaired health status or with expected medical care needs applies for insurance coverage financially favorable to himself or herself and detrimental to the insurance company
AGE DISCRIMINATION IN EMPLOYMENT ACT (ADEA)
Protects workers over 40 from compulsory retirement at any age as long as they are capable of performing their jobs adequately. It also protects them from adverse job actions based on age (e.g., refusal to hire; discriminatory layoff) and against benefits discrimination. Employers are subject to ADEA if they engage in an industry affecting interstate commerce and had 20 or more employees in each working day of 20 or more weeks in the current or preceding calendar year.
The total amount of out-of-pocket expenses that must be paid for health services by the insured and his/her family before becoming payable by the carrier.
Charges for services rendered or supplies furnished by a health provider which would qualify as covered expenses and for which the program will pay in whole or in part, subject to any deductible, coinsurance or table of allowance included in the program.
Person named by the participant in an insurance policy or pension plan to receive any benefits provided by the plan if the participant dies. A person designed by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit there under.
Period for application of deductibles, after which time deductibles must again be satisfied.
A drug protected by a patent issued to the original innovator or marketer. The patent prohibits the manufacture of the drug by other companies as long as the patent remains in effect.
Aon employee benefit plan that offers participants a choice between cash and one or more qualified, or tax-favored, benefits. To obtain the benefit of tax-favored treatment, the plan must comply with Internal Revenue Code Section 125. Typical benefits include health insurance, group term life and dental benefits. See also Flexible Benefit Plan; Section 125 Plan.
CALENDAR YEAR DEDUCTIBLE
A deductible that applies to any eligible medical expenses incurred by the insured during any one calendar year.
Use of a drug benefit identification card which, when presented to a participating pharmacy by employees or their dependents, usually entitles them to receive the medication for a minimal copay.
A utilization management technique that focuses on coordinating a number of health care and disability services needed by clients. It includes a standardized, objective assessment of client needs and the development of an individualized service or care plan that is based on the needs assessment and is goal oriented.
CERTIFICATE OF CREDITABLE COVERAGE
Notes the amount of previous qualified health coverage; required by HIPAA in certain circumstances.
CERTIFICATE OF INSURANCE
A document that is given to insured members of a group insurance plan and that outlines the plan’s coverage and the member’s rights.
A policy provision, frequently found in major medical insurance, by which both the insured person and the insured share the hospital and medical expense resulting from an illness or injury in a specified ratio (e.g., 80% / 20%), after the deductible is met. A form of cost-sharing.
COMPREHENSIVE MAJOR MEDICAL COVERAGE
This coverage provides protection similar to a combined basic and major medical plan and is often characterized by a low deductible, less than 100% reimbursement and a high maximum benefit. A typical type of comprehensive plan provides that most types of medical expenses are covered, usually after the satisfaction of a relatively low initial deductible (such as $100). After covered expenses exceed this initial deductible, the plan typically pays: (1) 100% of certain kinds of expenses up to a certain limit (such as 100% of the first $2,000 of covered hospital expenses after the deductible); (2) a percentage, such as 80% or 85% of all other covered medical expenses, including the expenses that exceed the limit mentioned in item (1).
The process by which hospital admissions for elective and emergency treatment are certified for appropriateness at the time of service and by which continued stays are verified for medical necessity and level of care
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA)
Among the provisions of this legislation that deal with health care coverage are the following: (1) employer-provided medical plans can no longer require Medicare to be the primary payer for participants age 70 and over; (2) Medicare coverage is extended to state and local government employees; (3) almost every group health plan must provide each participant and qualified beneficiary under the plan the option to pay for continued coverage for a specified period of time under the plan in the event coverage would otherwise have ceased as a result one of a number of “qualifying events.”
COORDINATION OF BENEFITS (COB)
A group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts.
Payments made by consumers, in addition to deductibles and coinsurance, to discourage inappropriate utilization and to help finance health benefit plans. See also Coinsurance; Deductible.
Methods and programs designed to contain costs by ensuring appropriateness, medical necessity and relatedness of treatment and procedures. Examples include utilization review and bill review.
Arrangements whereby consumers pay a portion of the cost of health services, sharing costs with employers. Deductibles, copayments, coinsurance and payroll deductions are forms of cost sharing.
Policies designed to shift the relative burden of health care costs borne by one party or market segment to another. Fox example, many employers are shifting a portion of the cost of care to employees by copayments and increased contributions
Describes the number or percentage of employees eligible for participation under an employee benefit plan. Benefits available to eligible individuals under an employee benefit program. With reference to revenue and corporate bonds, it indicates margin of safety for payment of debt service, reflecting the number of times by which earnings for a period of time exceed debt service payable in such period.
Under HIPAA, health care coverage used to reduce preexisting condition exclusion periods.
The amount of out-of-pocket expenses that must be paid for health services by the insured before becoming payable by the carrier. Most common in major medical policies, but also found in basic policies. See also Family Deductible; First Dollar Coverage
Generally the spouse or child of a covered individual, as defined in a contract. Can be any person who relies on, or obtains coverage through, a covered individual.
A condition that renders an insured person incapable of performing one or more duties of his or her regular occupation. Benefit plan definitions of disability vary. The Social Security Act defines disability as follows: Total disability is the inability to engage in any substantial, gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months (and which precludes the claimant from performing not only his pervious work, by considering his age, education and work experience any other kind of substantial gainful work which exists in the national economy regardless of whether such work exits in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applies for the work).
Periodic payments, usually monthly, payable to participants under some retirement plans if such participants are eligible for the benefits and become totally and permanently disabled prior to the normal retirement date. Includes short-term and long-term disability benefits.
DISABILITY INCOME INSURANCE
A form of health insurance that provides periodic payments to replace a certain percentage of income when the insured is unable to work as a result of illness, injury or disease.
The loss, or loss of use, of a limb or loss of sight from an injury
DOMESTIC PARTNER COVERAGE
Benefit coverage that recognizes as a family the ongoing, personal, intimate and committed relationship between two unrelated people of the same or opposite set that is the approximate equivalent of marriage, but does not involve formal marriage. Benefit plans that recognize domestic partnerships treat the partners of participants as if they were spouses. Also known as co-habitants, life partners, or spousal equivalents.
A restricted list of prescription medications covered under a managed care plan, which are approved for use for specific treatments and dispensed through participating pharmacies to plan members.
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An employment-based health service program designed to assist in the identification and resolution of a broad range of employee personal concerns that may affect job performance. These programs deal with situations such as substance abuse, marital problems, family troubles, stress ad domestic violence, as well as health education and disease prevention. The assistance may be provided within the organization or by referral to outside resources.
EVIDENCE OF INSURABILITY
Any statement or proof of a person’s physical condition, occupation or other factor affecting his acceptance for insurance. Usually not required for enrollment in group plans, and prohibited for COBRA continuation coverage.
The process of determining the premium rate for a group risk, wholly or partially on the basis of that group’s experience.
A provision inmost group policies for the return of premium to the policyholder because of lower than anticipated claims.
A premium based on the anticipated claims experience of, or utilization of service by, a contract group according to its age, sex and any other attributes expected to affect its health service utilization. Such a premium is subject to periodic adjustment in line with actual claims or utilization experience. (Antonym: community-rated premium)
EXPLANATION OF BENEFITS (EOB)
A statement from the insurer sent to a group member who files a claim giving specific details about how and why benefit payments were or were not made. It summaries the charges submitted and processed, the amount allowed, the amount paid, and the subscriber balance, if any.
FAMILY AND MEDICAL LEAVE ACT OF 1993 (FMLA)
Requires employers with more than 50 employees to provide workers with up to 12 weeks of unpaid leave each year for birth, adoption, foster care placement, and illnesses of employees and their families.
a deductible that is satisfied by the combined expenses of all covered family members. For example, a program with a $100 deductible may limit its application to a maximum of three deductibles ($300) for the family, regardless of the number of family members. An aggregate family deductible may be met by one or more family members. See also Deductible.
FIRST DOLLAR COVERAGE
A benefit plan which provides reimbursement for incurred health care costs “from the first dollar,” with no deductible.
FLEXIBLE BENEFIT PLAN
A benefit program under Section 125 of the Internal Revenue Code that offers employees a choice between permissible taxable benefits, including cash, and nontaxable health and welfare benefits such as life and health insurance, vacation pay, retirement plans and child care. Although a common core of benefits may be required, the employee can determine how his or her remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes employee contributions may be made for additional coverage.
FLEXIBLE SPENDING ACCOUNTS (FSAS)
Many flexible benefit programs include flexible spending accounts, which give employees the opportunity to set aside pretax funds for the reimbursement of eligible tax-favored welfare benefits. FSAs can be funded through salary reduction, employer contributions or a combination of both. Employees can purchase additional benefits, pay health insurance deductibles and copayments, or pay for child care benefits with the money in their FSAs.
See Prescription Drug Formulary.
A primary care provider (PCP) responsible for managing medical treatment rendered to an enrollee of a health plan. Alternatively, this term has been used to describe third party monitoring of care to avoid excessive costs by allowing only appropriate and necessary care to be rendered.
GENERIC EQUIVALENT DRUGS
Equal in therapeutic power to the brand-name originals because they contain identical active ingredients at the same doses.
A contract of insurance made with an employer or other entity which covers a group of persons identified by reference to their relationship to the entity buying the contract; e.g., member of a trade association, employees of a common employer, members of a labor union; or members of some other group or association not formed for the purpose of buying insurance.
Any insurance plan under which a number of employees and their dependents are insured under a single policy, issued to their employer, with individual certificates given to each insured employee; the most commonly written lines are life and accident and health.
GUARANTEED ISSUE UNDERWRITING
The insurer will issue up to some stipulated amount of insurance for each individual employee without evidence of insurability. The requirements are usually based on size of group and distribution by ages, and amounts are decided on by individual insurers.
HEALTH CARE COALITION
An organization working on broad health care concerns, including group purchasing, controlling costs and enhancing quality. Participants can be providers, business, third-party payers and consumers; often there is government participation as well.
Protection that provides payment of benefits for covered sickness or injury. Included under this heading are various types of insurance such as accident insurance, disability income insurance, medical expense insurance and accidental death and dismemberment insurance.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
Federal legislation that improves access to health insurance when changing jobs by restricting certain preexisting condition limitations, and guarantees availability and renew ability of health insurance coverage for all employers regardless of claims experience or business size. The law also increases the health insurance deduction for the self-employed; provides tax incentives for purchase of long-term care insurance; and establishes medical savings accounts (MSAs), which provide for tax deductible contributions to accounts to cover medical expenses.
HEALTH MAINTENANCE ORGANIZATION (HMO)
A pre-paid medical group practice plan that provides a comprehensive predetermined medical care benefit package. The HMO can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies and hospital-medical plans. HMOs are both insurers and providers of health care.
INCOME PROTECTION INSURANCE POLICY
A disability income policy which specifies that an insured is disabled if he or she suffers an income loss caused by a disability, therefore qualifying him or her for benefits under the policy.
INCURRED BUT NOT REPORTED (IBNR)
Claims that have been incurred but have not been reported to the insurer as of some specific date. Often a disputed figure since carriers must estimate this liability for accounting purposes based on their experience with claims lags.
In these traditional fee-for-service group health insurance plans, the patient chooses whichever doctor and hospital he or she wants to use. The employer pays premiums to the health insurance company to cover the costs of providing benefits and administering claims. The employee may pay a portion of the monthly insurance premium, an annual deductible and/or copayments per medical visit. These plans are usually experience rated, and health care providers are paid on a cost-plus, retroactive reimbursement system. The insurance carrier uses the premiums to pay claims and for retention fees, including state premium taxes, administrative expenses, commissions, risk charges and claims processing. The employer has no liability for a deficit.
Drugs that must be obtained by doctor prescription, as opposed to those prescribed by a doctor but available over the counter
A type of insurance that provides a sum of money if the person who is insured dies while the policy is in effect
LONG TERM CARE (LTC)
Includes all forms of services, both institutional and non-institutional, that are required by all people with chronic health conditions
LONG TERM DISABILITY INCOME INSURANCE
Insurance issued to an employer (group) or individual to provide a reasonable replacement of a portion of an employee’s earned income lost through serious and prolonged illness or injury during the normal work career.
MAIL-ORDER DRUG PROGRAM
A method of dispensing medication directly to the patient through the mail by means of a mail-order drug distribution company. Offers greatly reduced costs for prescriptions, especially for long-term therapy.
MAJOR MEDICAL COVERAGE
Supplementary insurance coverage (beyond basic medical) intended to cover the costs associated with a major illness or injury. Although characterized by large maximum limits, some limitations apply. The term can also refer to the catch-all portion of a medical plan that picks up payment for miscellaneous charges.
An approach to health care cost-containment whose goal is to deliver cost-effective care without sacrificing quality or access. The techniques used by managed care programs include case management; physician gatekeepers; provider networks; and components of utilization review such as preadmission certification, continued stay review, discharge planning and mandatory second-opinion programs. Managed care can be provided by HMOs, PPOs, exclusive provider organizations (EPAs) or managed indemnity plans.
A specific set of benefits required by law to be provided by all insurance carriers and reimbursed under all insurance policies
A life insurance policy that insures a number of people under a single insurance contract; a contract between an insurance company and a group policyholder in which the individuals insured are not parties to the contract
MEDICAID (TITLE XIX)
A medical benefits program administered by the state and subsidized by the federal government that pays certain medical expenses for those who meet income and other guidelines.
Administered by the Social Security Administration, Medicare is the U.S. federal government plan for paying certain hospital and medical expenses for those who qualify, primarily those over 65. The program is government subsidized and government operated. Part A, Hospital Insurance (HI), provides for inpatient hospital services and post-hospital care. Part B, Supplementary Medical Insurance (SMI), pays for medically necessary doctors’ services, outpatient hospital services and a number of other medical services and supplies not covered by Part A. Enrollment in Part B is voluntary and available for a small premium. Part C, Medicare+Choice, offers beneficiaries choices among managed care plans in addition to traditional fee-for-service Medicare.
MEDICARE SUPPLEMENT POLICY
A voluntary contributory private insurance plan available to Medicare eligibles to cover the costs of deductibles, coinsurance, physicians’ services and other medical and health services not covered by Medicare. Also called Medicap.
MENTAL HEALTH PARITY ACT OF 1996
Key provision: Plans that offer mental health benefits are prohibited from imposing aggregate lifetime or annual dollar limits for mental health benefits that are less than those imposed on medical/surgical benefits. Substance abuse treatment is excluded.
A period during which subscribers in a health benefit program have an opportunity to select an alternate health plan being offered to them; or a period when uninsured employees and their dependents may obtain coverage without presenting evidence of insurability.
OUT-OF-AREA BENEFITS (HMO)
Those benefits that the plan supplies to its subscribers when outside the geographical limits of the HMO. These benefits usually include emergency care benefits plus low indemnity payments for non-emergency benefits. Most plans stipulate that area services for emergency care will be provided until the subscriber can be returned to the plan for medical management of the case.
An illness or injury which prevents an insured person from performing one or more of the functions of his regular job
POINT OF SERVICE PLAN (POS)
A type of managed care plan that allows members to choose, at the point where care begins, to receive services from a participating or nonparticipating network provider, usually with a financial disincentive of r going outside the network. More of a product than an organization, POS plans can be offered by HMOs, PPOs or self-insured employers.
See Prior Authorization.
The process of obtaining certification or authorization from the health plan for hospital admissions (inpatient or outpatient) or for surgery, based on the judgment of medically appropriate care by a qualified peer. Failure to obtain pre-certification often results in a financial penalty to either the provider or the subscriber. Also known as pre-admission certification or pre-admission review.
PREADMISSION TESTING (PAT)
A plan benefit designed to encourage patients to obtain needed diagnostic services on an ambulatory basis before a non-emergency hospital admission in order to reduce hospital length of stay.
PREEMPTION OF STATE LAW (ERISA)
the regulatory portion of ERISA supersedes all state law which other wise would be applicable to plans covered by the reporting, disclosure, fiduciary responsibility, participation and vesting, funding and plan termination insurance provisions of ERISA. However, the preemptive effect of the act does not relieve any person from state law regulating insurance, banking or securities. Nor does the act preempt any generally applicable state criminal law.
A physical and/or mental condition of an insured person that existed prior to the issuance of his or her policy. Some plans may cover these conditions after a waiting period of six months to a year, while others may permanently exclude a person with a preexisting condition from coverage. See HIPAA.
PREFERRED PROVIDER ORGANIZATION (PPO)
A managed care plan that contacts with employers, insurance companies or other third party administrators to provide comprehensive medical service. Providers exchange discounted services for increased volume and prompt payment. Participants’ out-of-pocket costs are usually lower than under a fee-for-service plan.
PRESCRIPTION DRUG FORMULARY
A listing of prescription medications that will be covered by a plan or insurance contract that often fosters substitution of generic or therapeutic equivalents on a cost-effective basis.
PRESCRIPTION DRUG PLAN
Usually a provision under medical coverage plans whereby the beneficiary can obtain prescription drugs without incurring potentially large out-of-pocket expense. Different types of prescription drug plans are available. Examples are discount plan, closed panel drug plan, service-delivered plan, mail-order plan and maintenance drug option with major medical plan.
PRIMARY CARE PHYSICIAN (PCP)
The physician in a managed care plan who is responsible for coordinating all care for an individual patient, from providing direct care services to referring the patient to specialist and hospital care.
A cost-control procedure that requires the service or medication to be approved in advance by the doctor and/or the insurer. Without prior authorization, the health plan or insurer will not pay for the test, drug or services.
REASONABLE AND CUSTOMARY (R&C) CHARGE
The prevailing charge made by physicians of similar expertise for a similar procedure in a particular geographic area. See also Usual, Customary and Reasonable Fees.
An added level of coverage purchased by a self-funded employer, at-risk managed care plan or another insurance company to protect against a payout of claims in excess of a designated limit, to protect themselves from major losses or catastrophic claims. See also Stop Loss Insurance.
Arrangement by which a policyholder agrees to pay an additional premium at the end of the contract year if claims and retention exceed paid premium.
An insurance plan for which the premium is not determined until the completion of the coverage period, and is then based upon the plan’s actual experience for that period, subject to a stated minimum and maximum, and providing for recovery of expense and administrative factors. See also Experience Rating.
SECOND SURGICAL OPINION PROGRAM (SSOP)
This cost management strategy encourages or requires participants to obtain the opinion of another doctor after a physician has recommended that a non-emergency or elective surgery by performed. Programs may by voluntary or mandatory in that reimbursement is reduced or denied if the participant does not obtain the second opinion. Plans usually require that such opinions be obtained from board-certified specialists with no personal or financial interest in the outcome.
SECTION 125 PLAN
A plan in compliance with Section 125 of the IRC, which protects an employee from constructive receipt of the cash he or she has as a choice of benefits under a cafeteria plan. This means that employee contributions to a Section 125 plan may be made with pretax dollars. Also called Flexible Benefit Plan.
A fully noninsured or self-insured plan is one in which no insurance company or service plan collects no premiums and assumes risk. In a sense, the employer is acting as an insurance company-paying claims with the money ordinarily earmarked for premiums. Regardless of the specific self-funding technique a firm chooses, it will need to either buy its administrative services (ASO) outside the company or develop them in-house. Hence, self-funded arrangements are referenced as ASO or self-administered. There are two standard self-funding techniques that companies interested in this approach usually evaluate for appropriateness to their own situation: 5019(c) (9) trust and disbursed self-funded plan.
SHORT TERM DISABILITY INCOME INSURANCE
A provision to pay benefits to a covered disabled person as long as he remains disabled up to a specified period.
Contract established between a self-insured group and an insurance carrier providing carrier coverage if claims exceed specified dollar amount over a set period of time. May apply to an entire plan or a single component. Also called excess loss insurance.
A health insurance policy provision. A stop-loss provision is determined in two ways: either after a certain amount of benefits are paid from the plan or after a certain amount of out-of-pocket expenses are paid by the individual or family unit. When the dollar amount specified is reached, the coinsurance factor is raised to 100%. When there is a stop-loss provision in the plan (besides the separate maximums and coinsurance levels on outpatient mental and nervous disorders), outpatient mental and nervous charges usually do not apply toward the dollar figure used to calculate when the stop-loss begins; after the stop-loss does begin, it does not apply to these changes.
SUMMARY PLAN DESCRIPTION (SPD)
A requirement of ERISA for a written statement of a plan in an easy-to-read form, including a statement of eligibility, coverage, employee rights and appeal procedure. It is provided to participants, beneficiaries and, upon request, the Department of Labor.
SUPPLEMENTAL MAJOR MEDICAL COVERAGE
This coverage is designed to insure expenses not covered by a basic plan. Covered persons are first reimbursed for their medical expenses under the employer’s basic plan, usually with no deductible or copayment applied, to the extent that the basic plan covers the expenses. Expenses not covered by the basic plan can be reimbursed under the supplemental major medical plan, usually after the satisfaction of a corridor type deductible. After the covered expenses exceed the deductible, the major medical plan takes over and typically pays a percentage, such as 80%, of the covered expenses in excess of the deductible amount. There frequently is a limit on the amount of covered expenses that are subject to a coinsurance provision, after which the covered expenses are reimbursed in full.
SUPPLEMENTAL MEDICAL INSURANCE (SMI)
Also known as Medicare Part B, it is a voluntary insurance program which provides insurance benefits for physician and other medical services in accordance with the provisions of Title XVIII of the Social Security Act for aged and disabled individuals who elect to enroll under such program. See Medicare.
Life insurance payable to a beneficiary only when an insured dies within a specified period. There are no permanent policy benefits such as cash or loan value. Premiums are age based.
THIRD PARTY ADMINISTRATOR (TPA)
The party to an employee benefit plan that may collect premiums, pay claims and/or provide administrative services. Usually an out-of-house professional firm providing administrative services for employee benefit plans. (Synonyms: administrative agent, contract administrator)
THIRD PARTY PAYER
The insurer who pays for the services provided to a patient. Can be an insurance company, the government, a self-insured employer or a managed care organization.
An illness or injury that prevents an insured person from continuously performing every duty pertaining to his or her occupation or from engaging in any other type of work for remuneration. (This definition varies among insurance policies and benefit plans.) See also Disability.
A legal entity that is created when a person or organization transfers assets to a trustee for the benefit of designated persons.
A fund whose assets are managed by a trustee or a board of trustees for the benefit of another party or parties. Restrictions as to what the trustee may invest the assets of the trust fund in are usually found in the trust instrument and in applicable state and federal laws. In the case of ERISA-controlled employee benefit plan trust funds, there are specific requirements which should be referred to.
USUAL, CUSTOMARY AND REASONABLE (UCR) FEES
Usual is the fee which charged for a given service by a health care provider, customary is a fee in the range of usual fees charged by similar providers in area; reasonable is a fee that, according to the review committee, meets the lesser of the two criteria or is justified in the circumstances. Reimbursement is limited to the lowest of the three charges. Usual and customary charges are also being applied to workers’ compensation. See also Reasonable and Customary (R&C) Charge
UTILIZATION REVIEW (UR)
The evaluation of medical necessity, efficiency or quality of health care services, either prospectively, concurrently, or retrospectively. The term utilization review is more limited to the physician’s diagnosis treatment and billing amount.
VISION CARE COVERAGE OR PLAN
A separate plan covering medical treatment relating to eye conditions. Ophthalmologists, optometrists or opticians can render care.