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Phone Number (800) 44-BOTOX, Option 4

Monday through Friday
9:00am- 8:00pm ET
PO Box 220350 
Charlotte, NC 28222-0350

Your Provider Resource Center for Service and Information Relating to BOTOX® Reimbursement
Click here to see Important Information about Botox (onabotulinumtoxinA)



Allowed Amount
The maximum amount of the charges billed by the physician that the health plan will pay for the medical services rendered.


Benefit Penalty
A method used by the health plan to reduce payment on a claim when the patient or medical provider does not fulfill the rules of the health plan.

A method of reimbursement that combines payment for two or more related medical services.


A set dollar amount received or paid out based on membership of a health plan rather than actual medical services. Payment is based on a calculation known as per member per month (PMPM).

A set of medical services or plan benefits that are carved out and contracted for separately. This may also apply to services carved out from a capitation rate with a physician.

Case Management
A method of coordinating medical services to improve continuity and quality of patient care, with the intention of reducing cost. A case manager coordinates health care delivery for patients.

A request for payment by a medical provider or the patient for a given medical item or service.

Closed Access/Closed Panel
A managed health care plan that requires patients to designate and receive initial care from a primary care physician (PCP). The PCP must refer the patient for more specialized care.

CMS 1500
A standard claim form use by practitioners to bill health plans for medical services.

COBRA (Consolidated Omnibus Budget Reconciliation Act)
Federal legislation that requires employers to offer former employees and their dependents the opportunity to purchase a continuation of health care coverage.

A cost-sharing requirement under a health plan whereby the member will assume a portion or percentage of the costs of covered services. After the deductible is paid, this provision obligates the member to pay a certain percentage of any remaining medical bills, usually 20 percent.

Contracted Provider
A medical provider that has an agreement with a health plan to accept their patients at a previously agreed upon rate for payment.

Conversion Plan
When a member loses their group policy, and is ineligible for coverage under another group contract, the member has the option to continue coverage under an individual contract.

A fixed dollar amount the patient is responsible for each time a specific service is received, such as $10 for an office visit. This charge may be in addition to certain coinsurance and deductible payments.

Cost Containment
Efforts by the health plan to control health care costs by encouraging cost-effective services where appropriate.

Cost Sharing
The amount the patient is responsible for paying when they receive covered services. Cost sharing amounts include the deductible, co-payment, and coinsurance amounts.

Covered Services
The services, supplies, devices or drugs included as covered benefits under a health plan.


Required out-of-pocket expenditure by the patient before the health plan pays towards the allowable charges for a covered service.


Exclusive Provider Organization (EPO)
A form of a HMO whereby patients must use providers within the network to receive coverage.

Experimental or Unproven Procedures
Treatment the health plan deems medically unacceptable or scientifically unproven.

Explanation of Medical Benefits (EOMB)
A summary sent to the medical provider and patient by the health plan explaining the reasons why a claim was paid or denied.

Extension of Benefits
An additional 12 months of coverage, extended by the health plan due to a patient's disabling condition.


Fee Schedule
A listing of the maximum fee that a health plan will pay for a certain service based on CPT billing codes.

The listing of brand name and generic drugs covered and reimbursed by the health plan.



Health Maintenance Organization (HMO)
A health plan that provides comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed structure or capitated rates.


ICD-9 (International Classification of Diseases 9th Edition)
The classification of disease by diagnosis coding to identify the illness, injury or diseases.

Indemnity Plan
A health plan where members can choose their own physician, and reimbursement to the physician is based on a set fee each time they deliver a service.

IPA (Independent Practice Association)
An organization that contracts with a managed health care plan to deliver services in return for a single capitated rate. The IPA in turn contracts with individual providers on a capitated or fee-for-service basis.




Lifetime Maximum
The maximum amount that a health plan will pay for all the eligible medical expenses the individual incurs while insured under the policy.


Managed Health Care
A system of health care delivery that attempts to manage the cost, quality, and access to health care.

Medical Necessity
Services and supplies that the health plan deems appropriate with regard to standards of good medical practice, appropriate to the illness or injury for which they are performed, and not considered experimental, investigational, or cosmetic.



Open Access/Open Panel
A managed health care plan that allows patients to see another medical professional in the network, usually a specialist, without a gatekeeper referral.

Out of Pocket Maximum
An annual limit on how much in deductibles and co-payments the patient is required to pay before covered services are paid at 100 percent of the allowed charges for the rest of the calendar year.


Participating Provider
A health care provider who has a contractual arrangement to accept a set fee for services provided to members of a specific health plan.

Point of Service (POS) Plan
A health plan where members can choose between services from a provider in the plan network or outside the network, with varying levels of reimbursement.

Preferred Provider Organization PPO
A health plan that contracts with independent providers at a discount for service.

Pre-Existing Condition
A medical condition for which a member has received treatment during a specified period of time before becoming covered under a health plan.

A prospectively determined rate for insurance coverage for specific health benefits.

Primary Care Physician (PCP)
A physician designated as responsible to provide specific care to a patient, including evaluation and treatment as well as referral to specialists.

Prior Approval
An authorization for the delivery of services that must be obtained prior to the delivery of those services.




A health plan where the risk for medical cost is assumed by the employer rather than the insurance company or managed health care plan.


Third Party Administrator (TPA)
A firm that provides claims administration services, specializing in the management of self-insured benefit programs.


A standard claim form use by hospitals to bill health plans for medical services.

Usual, Customary, and Reasonable Charges (UCR)
Charges for health care services in a geographical area that are consistent with the charges of identical or similar providers in the same geographic area.



Waiting Period
A specified period of time a member must wait to become eligible for benefits for a specific condition(s), beginning on the effective date of the health plan.




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