Maximum Allowable Charge definition
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under the Plan. The Maximum Allowable Charge will always be a negotiated rate, if one exists; if no negotiated rate exists, the Maximum Allowable Charge will be determined and established by the Plan, at the Plan Administrator's discretion, using normative data and submitted information such as, but not limited to, any one or more of the following, in the Plan Administrator’s discretion:
Maximum Allowable Charge means the amount payable for a specific covered item under this Plan. The Maximum Allowable Charge will be a negotiated rate, if one exists.
Maximum Allowable Charge means the maximum reimbursement payable to a Participating Provider for Covered Services under the terms of this Contract.
Examples of Maximum Allowable Charge in a sentence
Maximum Allowed Cost and/or Maximum Allowable Charge shall mean the maximum amount payable for a Covered Service under the Contract and meeting Medical Necessity and Prior Authorization requirements.
DoD will reimburse DVA facilities CHAMPUS Maximum Allowable Charge (CMAC) minus 10 percent.
Reimbursement shall be based on a percentage discount off the CHAMPUS Maximum Allowable Charge (CMAC), the state prevailing, Diagnosis Related Group (DRG), or other methodology such as per diems for all types of services.
Reimbursement shall be based on a percentage discount off the CHAMPUS Maximum Allowable Charge (CMAC), the state prevailing, Diagnostic Related Group (DRG), or other methodology such as per diems for all types of services.
Out of network Class II, III, and IV claims will be paid at the Maximum Allowable Charge rate.
More Definitions of Maximum Allowable Charge
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under this Plan. The Maximum Allowable Charge will be a negotiated rate, if one exists.
Maximum Allowable Charge means the highest dollar amount of reimbursement allowed by either the primary or secondary plan for a particular covered service. Such amount is based on the fees negotiated between the claims administrator and certain physicians, health care professionals or other providers and whether covered services are received from providers contracting with the claims administrator or not contracting with the claims administrator. Reimbursement for services provided by non-contracting providers will be the stated percentage of the maximum allowable charge or billed charges, whichever is less. Contracting providers shall mean providers contracting with the claims administrator or one of its affiliates.
Maximum Allowable Charge means the following: (a) a usual fee is defined as the charge made for a given service by a Doctor to the majority of his patients; and (b) a customary fee is one which is charged by the majority of Doctors within a community for the same services. All benefits are limited to Usual and Customary Charges.
Maximum Allowable Charge means, with respect to a charge by a Network Provider, the charge that is established by an agreement between the Plan and the Network Providers.
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under the Plan. The Maximum Allowable Charge will always be a negotiated rate, if one exists. If no negotiated rate exists, the Maximum Allowable Charge will be determined as follows.
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under this Plan. The Maximum Allowable Charge will be a negotiated rate, if one exists; if no negotiated rate exists, the Maximum Allowable Charge will be determined by the Plan to be the Medicare reimbursement rates presently utilized by the Centers for Medicare and Medicaid Services (“CMS”) either multiplied by 150%, or multiplied by a percentage that the particular Provider and/or others in the area customarily accept from all payers.
Maximum Allowable Charge means the maximum unit price for a Covered Drug included on the applicable MAC List as set forth on such MAC List. ● "MAC List" shall mean a then-current list maintained by CHLIC of prescription drugs, devices, supplies and over-the-counter drugs identified as readily available as a Generic Drug or generally equivalent to a Brand Drug (in which case it may also be on a MAC List) and that, in each case, are deemed to require or are otherwise capable of pricing management due to the number of manufacturers, utilization and/or pricing volatility. ● "Pharmacy Benefits" shall mean amounts payable for covered pharmacy benefit services and products under the terms of the Plan; Pharmacy Benefits shall be considered Plan Benefits for purposes of this Agreement. ● "P&T Committee" shall mean a committee comprised of both voting and non-voting Cigna-employed clinicians, Medical Directors and Pharmacy Directors and non-Employees such as Participating Providers that represent a range of clinical specialties. The committee regularly reviews pharmaceutical products, new pharmaceutical products, for safety and efficacy, the findings of which clinical reviews inform coverage status decisions made by the Business Decision Team. The P&T Committee’s review may be based on consideration of, without limitation, FDA-approved labeling, standard medical reference compendia, or scientific studies published in peer-reviewed English-language bio-medical journals. ● "PBM Proprietary Information" shall mean information relating to CHLIC's pharmacy benefit management products and services, including, without limitation, CHLIC's reporting and web-based applications, eligibility and adjudication systems and coding methodologies, system formats and databanks, clinical or formulary management operations or programs, information and agreements relating to Rebates and other financial information, prescription drug evaluation criteria and coverage policies, drug pricing information, including MAC List and Specialty Drug pricing, paid Claims information integrated into CHLIC's adjudication systems, and pharmaceutical manufacturer, vendor or pharmacy network agreements. ● “Prescription Drug Charge” shall mean the amount that, prior to application of the Plan’s cost-share requirement(s), Employer is obligated to pay for a Covered Drug dispensed at a Retail Pharmacy or Cigna Home Delivery Pharmacy, including any applicable Dispensing Fee, service fee, and tax. The Prescription Drug Charge may be ex...