Reasonable and Appropriate definition
Reasonable and Appropriate means an amount of Covered Charges that is identified as eligible for payment by the Plan Administrator in accordance with the terms of the Plan. These amounts may be determined and established by the Plan, at the Plan Administrator’s discretion, using normative data such as, but not limited to, the fee(s) which the provider most frequently charges the majority of patients for the service or supply, amounts the provider most often agrees to accept as payment in full either through direct negotiation or through a preferred provider organization network, average wholesale price, and/or manufacturer’s retail pricing, the prevailing range of fees charged in the same “area” by providers of similar training and experience for the service or supply, rates negotiated with the Plan, and/or Medicare reimbursement rates. Medicare rates plus 20% are generally considered to be the Reasonable and Appropriate (and thus maximum payable amount, however, the Plan Administrator may in its discretion, taking into consideration specific circumstances and negotiated terms, deem a greater amount to be payable, up to 150% of Medicare rates. For purposes of defining “Reasonable and Appropriate,” the terms(s) “same geographic locale” and/or “area” shall be defined as a metropolitan area, county, or such greater area as is necessary to obtain a representative cross-section of providers, person or organizations rendering such treatment, services, or supplies for which a specific charge is made. Reasonable and Appropriate claims shall be limited to those claims that, in the Plan Administrator’s discretion, are services or supplies or fees for services or supplies that are necessary for the care and treatment of Illness or Injury not unreasonably caused by the treating provider. The determination whether fee(s) or services are Reasonable and Appropriate will be made by the Plan Administrator, taking into consideration such factors as,, but not limited to, the findings and assessments of the following entities: (a) national medical associations, societies, and organizations; and (b) the Food and Drug Administration. To be Reasonable and Appropriate, services(s) and/or fee(s) must be in compliance with generally accepted billing practices for unbundling or multiple procedures. Services, supplies, care and/or treatment that results from errors in medical care that are clearly identifiable, preventable, and serious in their consequence for patients, are not Reasonable and Appropriate. The ...
Examples of Reasonable and Appropriate in a sentence
Reasonable and Appropriate amounts will be determined by the Foundation.