The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured.
Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
Capitation Rate (cap rate)
The contractually set periodic prepayment to a provider for specified services to each enrolled plan member.
Consumer-driven health plan (CDHP)
Type of medical insurance that combines a high-deductible health plan with a medical savings plan which covers some out-of-pocket expenses.
A negotiated payment schedule for health care services based on a reduced percentage of a provider's usual charges.
A fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.
List of charges for services performed.
Health Maintenance Organization (HMO)
A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
A fixed, periodic amount that must be met by each individual of an insured/dependent group before benefits from a payer begin.
Providers and suppliers who participate in a particular managed care organization or health plan.
Nonparticipating (nonPAR) physician
A physician or other health care provider who chooses not to join in a particular government or other program or plan.
Providers or suppliers who do not participate in a managed care organization or health plan.
Expenses the insured must pay for a particular encounter before benefits begin.
Participating (PAR) physician
A physician who agrees to provide medical services to a payer's policyholders according to the terms of the plan or program's contract.
Point-of-service (POS) plan
In HMOs, a plan that permits patients to receive medical services from non-network providers; this choice requires a larger patient payment than visits with network providers.
Preferred Provider Organization (PPO)
A managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
Primary Care Physician (PCP)
A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
Discounting fees or not charging a physician's family members or other physicians for work performed.
Authorization number given by a referring physician to the referred physician.
Relative Value Scale (RVS)
System of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them.
Resource-Based Relative Value Scale (RBRVS)
Federally mandated relative value scale for establishing Medicare charges.
Usual, Customary, and Reasonable (UCR)
Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and what is reasonable considering the circumstances.
Fee for a service or procedure that is charged by a provider for most patients under typical circumstances.
A medical billing program report given to a patient that lists the diagnoses, services provided, fees, and payments received and due after an encounter.
Write Off (verb)
(N. write-off) To deduct an amount from a patient's account because of a contractual agreement to accept a payer's allowed charge or other reason.