Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. See ACA Uniform Glossary
Healthcare and health insurance definitions.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. See ACA Uniform Glossary
A formal process used by an insurer, or delegated by the insurer, to monitor a patient’s use of healthcare services and evaluate the medical necessity, appropriateness, efficacy, or efficiency of those services, procedures, or settings.