Allowed amount
The maximum amount your plan considers payable for a covered service. Calculated cost-sharing is based on this number.
The allowed amount is the dollar figure your plan uses as the basis for paying claims. For in-network services, it's the negotiated rate. For out-of-network, it varies — typically a UCR (usual, customary, reasonable) calculation or a percentage of Medicare. Your coinsurance and deductible apply to the allowed amount, not the provider's billed charge. Cap on patient cost-sharing applies to the allowed amount.
Frequently asked questions
What is allowed amount?
The allowed amount is the dollar figure your plan uses as the basis for paying claims. For in-network services, it's the negotiated rate. For out-of-network, it varies — typically a UCR (usual, customary, reasonable) calculation or a percentage of Medicare. Your coinsurance and deductible apply to the allowed amount, not the provider's billed charge. Cap on patient cost-sharing applies to the allowed amount.
Related terms
- CoinsuranceYour percentage share of a healthcare service cost after you've met your deductible — usually 10-30%
- Balance billingWhen an out-of-network provider bills you the difference between their charge and what your plan pai
- In-networkA provider, facility, or pharmacy that has a contract with your plan to provide services at negotiat
- Out-of-network (OON)A provider who doesn't have a contract with your plan. Cost-sharing is higher and you may face balan
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