Glossary

The updated estimate of the most recent historical year.

When a provider bills you for the balance remaining on the bill that your plan doesn't cover. This amount is the difference between the actual billed amount and the allowed amount. This happens most often when you see an out-of-network provider (non-preferred provider). These balance bill costs are in addition to what you pay out-of-pocket for out-of-network services according to your health plan coverage. An in-network provider (preferred provider) may not balance bill you for covered services.

A situation in which Private Fee-for-Service Plan providers (doctors or hospitals) can charge and bill you 15% more than the plan's payment amount for services.

The period from the end of World War II through the mid-1960s marked by unusually high birth rates.

A computation that is made on all marketable interest-bearing obligations of the United States. It is computed on the basis of market quotations as of the end of the calendar month immediately preceding the date of such issue.

Claim review and determination made using system logic (edits). Automated claim reviews never require the intervention of a human to make a claim determination.

MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)

Written medical or scientific conclusions demonstrating the medical effectiveness of a service produced by the following:

• Controlled clinical trials, published in peer-reviewed medical or scientific journals;
• Controlled clinical trials completed and accepted for publication in peer-reviewed medical or scientific journals;
• Assessments initiated by CMS;
• Evaluations or studies initiated by Medicare contractors;
• Case studies published in peer-reviewed medical or scientific journals that present treatment protocols.

Method or type of approval that requires a determination that the service is likely to have a diagnostic or therapeutic benefit for patients for whom it is intended.

Number of the licensed physician who would normally be expected to certify and recertify the medical necessity of the number of services rendered and/or who has primary responsibility for the patient's medical care and treatment.