Category: P

Medical practice in which the practitioner and his practice are independent of any external policy control. It usually requires that the practitioner be self-employed, except when he is salaried by a partnership in which he is a partner with similar practitioners. It is sometimes wrongly used synonymously with either fee-for-service practice (the practitioner may sell…

A patient whose care is the responsibility of an identifiable, individual health professional (usually o. physician) who is paid directly (by the patient or a third-party) for his service to the patient. The physician is called a personal physician and the patient is his private patient. Private patients are contrasted with public, service or ward…

Similar to prior authorization but less restrictive in that payment will be made if prior authorization is not sought, provided that it would have approved the service as needed.  

Requirement imposed by a third party, under some systems of utilization review, that a provider must justify before a peer review committee, insurance company representative, or State agent the need for delivering a particular service to a patient before actually providing the service in order to receive reimbursement. Generally, prior authorization is required for non-emergency…

That part of an insurance company’s reserves set aside for losses incurred but not reported (IBNR).  

Denotes insurer obligated to pay losses prier to any liability of other, secondary insurers. Under current law, Medicare is a primary payer with respect to Medicaid; for a person eligible under both programs, Medicaid pays only for benefits not covered under Medicare, or after Medicare benefits are exhausted.  

A charge which falls within the range of charges most frequently used in a locality for a particular medical service or procedure. The top of this range establishes an over-all limitation on the charges which a carrier, which considers prevailing charges in reimbursement, will accept as reasonable for a given service, without adequate special justification.…

In the Federal budget, the budget for a particular fiscal year specifying proposed budget authority, obligations and outlays transmitted to the Congress by the President in accordance with the Budget and Accounting Act of 1921, as amended. Some elements of the budget, such as the estimates for the legislative branch and the judiciary, are included…

Inconsistently used, sometimes synonymous with insurance, sometimes refers to any payment ahead of time to a provider for anticipated services (such as an expectant mother paying in advance for maternity care), sometimes distinguished from insurance as referring to payment to organizations (such as HMOs, prepaid group practices and medical foundations) which, unlike an insurance company,…

Generically, a contract between an insurer and a subscriber or group of subscribers whereby the PHP provides a specified set of health benefits in return for a periodic premium. The term now usually means organizational entities in California which provide services to Medical (the name for California’s Medicaid program) beneficiaries under contract with the State…