the charge most frequently made to the majority of patients for the same service or procedure. The charge must be within the range of the charges most frequently made in the same or similar medical service area for the service or procedure as billed by the other Physicians.
The amount Medicare determines to be the maximum amount allowable for any given service. There is a 5% differential between the approved charges for services rendered by participating providers and the approved charges for services rendered by nonparticipating providers. The participating approved amount is 5% higher.
The maximum reimbusement allowed for covered services. It can reflect a fee schedule or customary charges determined by WellChoice, WellChoice's agreement with a provider, or by statute or regulation (may be subject to a deductible or coinsurance).
The maximum reimbursement the member's health policy allows for a specific service in or out of network. This amount may be: -a fee negotiated with participating providers -a customary charge based on the amount -charged by most providers in the member's area -an allowance established by law -an amount set on a Fee Schedule of Allowance
Maximum dollar amount assigned for a procedure based on various pricing mechanisms. Also know as a maximum allowable.
The amount commonly charged for a particular medical service by physicians within a particular geographic region. Previously known as UCR (Usual, Customary and Reasonable fee), allowed amounts are used by traditional health insurance companies as the basis for physician reimbursements.
The maximum dollar amount a contract allows for services covered, regardless of the provider's actual charge. A provider who participates in the network cannot charge the member more than this amount for any covered service.
The amount of the billed charge for medical services that the insurance company determines is payable by the plan.
