A standard billing format for submitting hospital claims.
The billing of separate charges for services that are normally included under one procedure code.
Health care coverage for which the Blues assume the risk for the cost of all covered services.
A portion of the paid premium that applies to the unexpired portion of the contract term.
Services provided for a condition that occurs suddenly and unexpectedly and requires prompt diagnosis and treatment; otherwise, the member might suffer chronic illness, prolonged impairment or the need for more hazardous treatment. Fever, earache, most fractures, sprains, most lacerations, repeated kidney stones and dizziness are examples of conditions that are considered urgent.
usual customary and reasonable charge
A reimbursement methodology based on the amount a plan determines to be the prevailing charge for a particular covered service in the geographical area in which it is performed. Used now only to describe the reimbursement level for the automotive groups and the State of Michigan group.
A process of integrating review and case management of services in a cooperative effort with members, groups and providers to optimize cost-effective patient care that doesn’t minimize quality.
A system that analyzes the necessity, appropriateness and efficiency of the medical services and facilities used for patient care.