Medicare-allowed amount Definition | Law Insider (2023)

  • Medicare eligible expenses means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

  • Medicare benefit means the Medicare benefit payable within the meaning of Part II of the Health Insurance Act 1973 with respect to a professional service.

  • Allowed Amount means the maximum amount We will pay for the services or supplies covered under this Policy, before any applicable Copayment, Deductible and Coinsurance amounts are subtracted. We determine Our Allowed Amount as follows:

  • NOx Allowance means an authorization to emit a specified amount of NOx that is allocated or issued under an emissions trading or marketable permit program of any kind that has been established under the Clean Air Act or a state implementation plan.

  • Professional Fee Escrow Amount means the aggregate amount of Professional Fee Claims and other unpaid fees and expenses Professionals estimate they have incurred or will incur in rendering services to the Debtors prior to and as of the Confirmation Date, which estimates Professionals shall deliver to the Debtors as set forth in Article II.C hereof.

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  • Covered Amount means, for any Distribution Date with respect to the Controlled Accumulation Period or the first Special Payment Date, if such Special Payment Date occurs prior to the date the Class A Invested Amount is paid in full, an amount equal to the sum of (x) with respect to the Class A Certificates, the product of (i) the Class A Certificate Rate, (ii) a fraction, the numerator of which is the actual number of days from and including the prior Distribution Date to but excluding the then current Distribution Date and the denominator of which is 360 and, (iii) the Principal Funding Account Balance, if any, as of the preceding Distribution Date that is allocable to the principal of the Class A Certificates and (y) with respect to the Class B Certificates, the product of (i) the Class B Certificate Rate, (ii) a fraction, the numerator of which is the actual number of days from and including the prior Distribution Date to but excluding the then current Distribution Date and the denominator of which is 360 and (iii) the Principal Funding Account Balance, if any, as of the preceding Distribution Date that is allocable to the principal of the Class B Certificates.

  • Maximum Allowable Payment means the maximum amount, as established by AvMed, which AvMed will pay for any Covered Service rendered by a Non-Participating Provider or supplier of services, medications or supplies, except for Emergency Medical Services and Care as defined herein. The Maximum Allowable Payment may be changed at any time by AvMed without notice to you or your consent.

  • Non-Participating Certified Nurse-Midwife means a Certified Nurse-Midwife who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Excess Contribution means the excess of (i) the amount contributed for the tax year (other than a rollover contribution) over (ii) the amount allowable as a contribution. (c) Contributions shall be in accordance with this Agreement, but the Custodian will have no obligation to verify the allowability or amount of contributions and may rely solely on your representations with respect thereto.

  • Professional Fee Escrow Account means an interest-bearing account funded by the Debtors with Cash on the Effective Date in an amount equal to the Professional Fee Amount.

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  • Retirement allowance means the retirement payments to which a member is entitled;

  • Non-Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has not been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Insured Amount The meaning ascribed thereto in Section 4.09. Insured Depository Institution: Insured Depository Institution shall have the meaning ascribed to such term by Section 1813(c)(2) of Title 12 of the United States Code, as amended from time to time.

  • Maximum Contribution Amount shall equal the excess of (i) the aggregate proceeds received by such Holder pursuant to the sale of such Registrable Notes or Exchange Notes over (ii) the aggregate amount of damages that such Holder has otherwise been required to pay by reason of such untrue or alleged untrue statement or omission or alleged omission. No person guilty of fraudulent misrepresentation (within the meaning of Section 11(f) of the Securities Act) shall be entitled to contribution from any Person who was not guilty of such fraudulent misrepresentation. The Holders’ obligations to contribute pursuant to this Section 8(d) are several in proportion to the respective principal amount of the Registrable Securities held by each Holder hereunder and not joint. The Company’s and Guarantors’ obligations to contribute pursuant to this Section 8(d) are joint and several. The indemnity and contribution agreements contained in this Section 8 are in addition to any liability that the Indemnifying Parties may have to the Indemnified Parties.

  • Excess Compensation means the amount of the excess cash-based or equity-based incentive compensation equal to the difference between the actual amount received by the Covered Employee and the award or payment that would have been received based on the restated financial results during the three-year period preceding the date on which the Company is required to prepare such restatement (the “Covered Period”).

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  • Company Contribution Amount means, for any one Plan Year, the amount determined in accordance with Section 3.5.

  • Rollover Distribution shall be defined as set forth in Section 5.05, herein."

  • Excess Contributions means, with respect to any Plan Year, the excess of:

  • Partial Dependant means a "dependant" as prescribed in paragraph (a) of this subclause who receives a location allowance which is less than the location allowance prescribed in subclause (1) of this clause or who, if in receipt of a salary or wage package, receives less than a full consideration for which the location allowance is payable pursuant to the provisions of this clause.

  • Preferred Allowance means the amount a Preferred Provider will accept as payment in full for Covered Medical Expenses.

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  • Eligible Rollover Distribution means any distribution of all or any portion of the balance to the credit of the distributee, except that an Eligible Rollover Distribution does not include: any distribution that is one of a series of substantially equal periodic payments (not less frequently than annually) made for the life (or life expectancy) of the distributee or the joint lives (or joint life expectancies) of the distributee and the distributee's designated beneficiary, or for a specified period of ten years or more; any distribution to the extent such distribution is required under Section 401(a)(9) of the Code; any hardship distribution described in Code Section 401(k)(2)(B)(i)(IV) received after December 31, 1998; and the portion of any distribution that is not includable in gross income (determined without regard to the exclusion for net unrealized appreciation with respect to employer securities).

  • Medicare Advantage plan means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:

  • Special Hazard Loss Coverage Amount With respect to the first Distribution Date, $5,000,000. With respect to any Distribution Date after the first Distribution Date, the lesser of (a) the greatest of (i) 1% of the aggregate of the principal balances of the Mortgage Loans, (ii) twice the principal balance of the largest Mortgage Loan and (iii) the aggregate of the principal balances of all Mortgage Loans secured by Mortgaged Properties located in the single California postal zip code area having the highest aggregate principal balance of any such zip code area and (b) the Special Hazard Loss Coverage Amount as of the Closing Date less the amount, if any, of Special Hazard Losses allocated to the Certificates since the Closing Date. All principal balances for the purpose of this definition will be calculated as of the first day of the calendar month preceding the month of such Distribution Date after giving effect to Scheduled Payments on the Mortgage Loans then due, whether or not paid.

  • Fraud Loss Coverage Amount As of the Closing Date, $4,000,000 subject to reduction from time to time, by the amount of Fraud Losses allocated to the Certificates. In addition, on each anniversary of the Cut-off Date, the Fraud Loss Coverage Amount will be reduced as follows: (a) on the first, second, third and fourth anniversaries of the Cut-off Date, to an amount equal to the lesser of (i) 1% of the then current Pool Stated Principal Balance and (ii) the excess of the Fraud Loss Coverage Amount as of the preceding anniversary of the Cut-off Date over the cumulative amount of Fraud Losses allocated to the Certificates since such preceding anniversary; and (b) on the fifth anniversary of the Cut-off Date, to zero.

  • Health care expenses means, for purposes of Section 14, expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of insurers.

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  • Fair Share Contribution Amount means, with respect to a Contributing Guarantor as of any date of determination, the maximum aggregate amount of the obligations of such Contributing Guarantor under this Guaranty that would not render its obligations hereunder or thereunder subject to avoidance as a fraudulent transfer or conveyance under Section 548 of Title 11 of the United States Code or any comparable applicable provisions of state law; provided, solely for purposes of calculating the “Fair Share Contribution Amount” with respect to any Contributing Guarantor for purposes of this Section 7.2, any assets or liabilities of such Contributing Guarantor arising by virtue of any rights to subrogation, reimbursement or indemnification or any rights to or obligations of contribution hereunder shall not be considered as assets or liabilities of such Contributing Guarantor. “Aggregate Payments” means, with respect to a Contributing Guarantor as of any date of determination, an amount equal to (1) the aggregate amount of all payments and distributions made on or before such date by such Contributing Guarantor in respect of this Guaranty (including in respect of this Section 7.2), minus (2) the aggregate amount of all payments received on or before such date by such Contributing Guarantor from the other Contributing Guarantors as contributions under this Section 7.2. The amounts payable as contributions hereunder shall be determined as of the date on which the related payment or distribution is made by the applicable Funding Guarantor. The allocation among Contributing Guarantors of their obligations as set forth in this Section 7.2 shall not be construed in any way to limit the liability of any Contributing Guarantor hereunder. Each Guarantor is a third party beneficiary to the contribution agreement set forth in this Section 7.2.

  • FAQs

    What does Medicare allowed amount mean? ›

    The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan's allowed amount, you may have to pay the difference. (

    How is the allowed amount determined? ›

    If you used a provider that's in-network with your health plan, the allowed amount is the discounted price your managed care health plan negotiated in advance for that service. Usually, an in-network provider will bill more than the allowed amount, but he or she will only get paid the allowed amount.

    What does 20% of allowable amounts mean? ›

    For example, if your health insurance plan's allowed amount for an office visit is $100 and your. coinsurance is 20%: • If you've paid your deductible: you pay 20% of $100, or $20. The insurance company pays the rest.

    What is the difference between billed amount and allowed amount? ›

    Billed charge – The charge submitted to the agency by the provider. Allowed charges – The total billed charges for allowable services. Allowed covered charges – The total billed charges for services minus the billed charges for noncovered and/or denied services.

    How is the Medicare allowed amount determined? ›

    The Medicare limiting charge is set by law at 115 percent of the payment amount for the service furnished by the nonparticipating physician. However, the law sets the payment amount for nonparticipating physicians at 95 percent of the payment amount for participating physicians (i.e., the fee schedule amount).

    How is the Medicare approved amount determined? ›

    The Medicare-approved amount is the amount of money that Medicare will pay a health care provider for a medical service or item. After you meet your Medicare Part B deductible ($233 per year in 2022), you will typically pay a percentage of the Medicare-approved amount for services and items covered by Medicare Part B.

    What is allowed amount? ›

    The allowed amount is the appropriate cost, decided by the insurance company, for the service provided by the medical professional. This allowed amount can be much lesser than the actual amount claimed by the medical service provider.

    Does Medicare payment 80 percent of the allowed amount? ›

    Medicare pays 80% of the approved charge. Either the patient or supplemental insurance pays the remaining 20% co-payment. No further payment is due to the physician. When a physician does not accept assignment, however, he or she may “balance bill” the patient above the Medicare approved charge.

    What does total allowable mean? ›

    The total allowable catch (TAC) is a catch limit set for a particular fishery, generally for a year or a fishing season. TACs are usually expressed in tonnes of live-weight equivalent, but are sometimes set in terms of numbers of fish.

    What does 80 of allowable amount mean? ›

    For example, an insurance company who contracts with a provider for a rate of 80% will allow bills for services only up to 80% and the difference between the allowed 80% amount and billed amount will not be covered by insurance company.

    What does 100% of allowable amount until deductible is met? ›

    A deductible is the amount you pay for health care services before your health insurance begins to pay. How it works: If your plan's deductible is $1,500, you'll pay 100 percent of eligible health care expenses until the bills total $1,500. After that, you share the cost with your plan by paying coinsurance.

    Why there is a difference between the amount billed allowed and paid? ›

    This difference has nothing to do with what the provider bills. It is entirely due to the rates negotiated and contracted by your specific insurance company. The provider MUST bill for the highest contracted dollar ($) amount to receive full reimbursement.

    Can a copay be more than the allowed amount? ›

    If the patient's copay is higher than the allowable, you will owe them a refund. You are not allowed to keep anything in excess of your contracted rate - that's called 'balance billing', and it's explicitly prohibited in the vast majority of physician/payor contracts.

    What is meant by allowed charge or allowable charge in insurance terms? ›

    Allowed Amount: Maximum dollar amount assigned for a procedure based on various pricing mechanisms. Also known as a maximum allowable. Allowable Charge: The maximum charge for which a third party will reimburse a provider for a given service.

    Why is Medicare approved amount different from Medicare paid? ›

    The Medicare-approved amount is the amount of money that Medicare has agreed to pay for your services. This amount can differ depending on what services you're seeking, and who you are seeking them from. Using a Medicare participating provider can help to lower your out-of-pocket Medicare costs.

    What are the 3 qualifying factors for Medicare? ›

    Be age 65 or older; Be a U.S. resident; AND. Be either a U.S. citizen, OR. Be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years prior to the month of filing an application for Medicare.

    What is the Medicare 80/20 rule? ›

    The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs. The 80/20 rule is sometimes known as Medical Loss Ratio, or MLR.

    Does everyone get the same amount of Medicare? ›

    Monthly premiums vary based on which plan you join. The amount can change each year. You may also have to pay an extra amount each month based on your income.

    What is the difference between billed amount and allowed amount in case of contracted provider's? ›

    The Amount Allowed is often less than the Amount Charged. Contracting or 'in-network' providers agree to accept the allowed amount (or tariff) which is also referred to as the maximum allowance based on an individual's policy.

    Why do doctors charge more than Medicare pays? ›

    A: It sounds as though your doctor has stopped participating with Medicare. This means that, while she still accepts patients with Medicare coverage, she no longer is accepting “assignment,” that is, the Medicare-approved amount.


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