The Independent Medical Review Program

Usual, Reasonable, and Customary – The amount that your insurance company determines is the normal payment range for a specific medical procedure performed within a given geographic area. If the charges you submit to your health insurancecompanyarehigher thanwhat isconsiderednormal forthecoveredhealthcareservices,thenyourhealthinsurance company may not allow the full amount charged to you, and you may be responsible for the balance. ERISA – The Employee Retirement Income Security Act (1974). Administered by the U.S. Department of Labor, ERISA regulates employer sponsored pension and insurance plans (self-insured plans) for employees. Exclusions and/or Limitations – Conditions or circumstances spelled out in an insurance policy which limit or exclude coverage benefits. It is important to read all exclusion, limitation, and reduction clauses in your health insurance policy or certificate of coverage to determinewhich expenses are not covered. Experimental and/or Investigational Medical Services – A drug, device, procedure, treatment plan, or other therapy which is currently not within the accepted standards of medical care. In Writing – The language in an insurance contract, code, or regulation which requires a request or action to be authorized by written correspondence and/or signature. Written correspondence includes letters, notes, and facsimile (fax) transmissions. Medically Necessary – A drug, device, procedure, treatment plan, or other therapy that is covered under your health insurance policy and that your doctor, hospital, or provider has determined essential for your medical well-being, specific illness, or underlying condition. Policy – The written contract between an individual or group policyholder and an insurance company. The policy outlines the duties, obligations, and responsibilities of both the policyholder and the insurance company. A policy may include any application, endorsement, certificate, or any other document that can describe, limit, or exclude coverage benefits under the policy. 10