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| Railroad Retirement |
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system which provides retirement and other Benefits, including eligibility forMedicare, for railroad workers.
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| Railroad Travel Policy |
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form of Accident Insurance Policy sold in railroad stations by ticket agents or by vending machines. See also Travel Accident Insurance.
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| Rate Spread |
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The difference between the highest and lowest rates that a Health Plan charges Small Groups. The NAIC Small Group Model Act limits a plan's allowable Rate Spread to 2 to 1.
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| Rating |
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The process of calculating the appropriate Premium to charge purchasers, given the degree of Risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability and competitiveness of the MCO's plan.
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| Rating Process |
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The steps used to determine a Premium rate for a particular Group based on the amount of Risk that Group presents. Items that generally go into the Rating process include age, sex, type of industry, Benefits, and administrative costs.
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| RBRVS |
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See Resource-Based Relative Value Scale (RBRVS).
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| Reasonable and Customary (R &C) Charge |
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A term used to refer to the commonly charged or prevailing fees for Health Services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. "Reasonable and Customary (R &C) Charge" essentially means the same thing as "Usual and Customary (U&C) Charge".
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| Rebate |
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A reduction in the price of a particular pharmaceutical obtained by a PBM from the pharmaceutical manufacturer.
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| Recidivism |
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This term refers to how often a patient returns to an Inpatient Hospital status for the same reason.
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| Recipient |
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Anyone designated byMedicaid as being eligible to receiveMedicaid Benefits.
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| Recredentialing |
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Reexamination by an MCO of the qualifications of a Provider and verification that the Provider still meets the standards for Participation in the Network.
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| Recurring Clause |
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Health Insurance (HI) Policy provision defining the duration of a period of time during which the recurrence of a condition will be considered a Continuation of a prior period of disability or confinement.
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| Referral |
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An OK from the Primary Care Physician (PCP) for the patient to see a specialist or get certain services. In many HMO plans, the insured person needs to get a Referral before they get care
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| Referral Provider |
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The person or Provider to whom a Participating Provider has referred a Member of the plan.
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| Registered Nurse (RN) |
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A licensed professional with a four-year nursing degree. Able to provide all levels of nursing care including the adminstration of medication.
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| Regular Care |
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means direct advice or direct supervision of treatment or therapy by a Physician who is competent to advise or supervise Your disability.
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| Rehabilitation Clause |
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A clause in a Health Insurance (HI) Policy, particularly a Disability Income policy, that is intended to assist the disabled Policyholder in vocational rehabilitation.
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| Rehabilitation Services |
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Specialized treatment for a Sickness or an Injury which meets all of the following requirements:
1. Is a program of services provided by one or more members of a Multi-Disciplinary team.
2. Is designed to improve the patient's function and independence.
3. Is under the direction of a qualified Health Care Practitioner.
4. Includes a formal written treatment plan with specific attainable and measurable goals and objectives.
5. May be provided in either an Inpatient or Outpatient setting.
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| Reinstatement |
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Resumption of Coverage under a Policy that has Lapsed because of nonpayment of the Premium after the grace period has ended.
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| Relative Value Of Services |
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See Relative Value Scale (RVS).
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| Relative Value Scale (RVS) |
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A method used by MCOs of determining Provider reimbursement that assigns a weighted value to each medical procedure or service. To determine the amount the MCO will pay to the physician, the weighted value is multiplied by a money multiplier. Also known as a Relative Value Of Services.
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| Relative Value Schedule |
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A Surgical Schedule which basically compares the value of one surgical procedure to another and establishes the surgical fee to be paid.
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| Relative Value Unit |
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Sometimes used instead of dollar amounts in a Surgical Schedule, this number is multiplied by a conversion factor to arrive at the surgical Benefit to be paid.
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| Renewal |
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A Continuation of an insurance Policy on revised terms, such as adjusted Health Insurance (HI) rates from anyone except the Primary Care Physician (PCP). If the Referral is not received, the HMO may cover resulting expenses.
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| Renewal Underwriting |
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The process by which an underwriter reviews each year all the selection factors that were considered when the contract was issued, then compares the group's actual Utilization rates to those the MCO predicted to determine the group's Renewal rate.
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| Report Card |
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A set of Performance Measures applied uniformly to different Health Plans or Providers.
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| Reserves |
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Estimates of money that an insurer needs to pay future business obligations.
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| Residual Disability |
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That form of disability which becomes defined as Partial Disability when an Insured has returned to work immediately following a period of
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.
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| Residual Income |
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A clause used with a disability income Policy that provides for Benefits to be paid when the Insured can do some but not all of his/her normal duties. For example, if the Insured suffers a disability that causes him or her to lose a third of his or her earning power, the residual diasability clause would provide one-third of the Benefit that the Policy would provide for
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.
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| Resource-Based Relative Value Scale (RBRVS) |
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A method used by MCOs of determining Provider reimbursement that attempts to take into account, when assigning a weighted value to medical procedures or services, all resources that physicians use in providing care to patients, including physical or procedural, educational, mental (cognitive), and financial resources.
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| Respite Care |
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Normally associated with Hospice Care, respite care is a Benefit to family members of a patient whereby the family is provided with a break or respite from caring for the patient. The patient is confined to a Nursing Home for needed care for a short period of time.
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| Restoration of Benefits |
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A provision in many Major Medical Plans which restores a person's Lifetime Maximum Benefit Amount in small increments after a Claim has been paid. Usually, only a small amount ($1,000 to $3,000) may be restored annually.
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| Retention |
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The portion of the Premium which is used by the insurance company for administrative costs.
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| Retrospective Authorization |
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Authorization to deliver healthcare service that is granted after service has been rendered.
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| Retrospective Rate Derivation (RETRO) |
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ARating system whereby the employer becomes responsible for a portion of the group's health care costs. If health care costs are less than the portion the employer agrees to assume, the insurance company may be required to refund a portion of the Premium.
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| Return of Premium |
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A Rider or provision in a Health Insurance (HI) Policy agreeing to pay a Benefit equal to the sum of all the Premiums paid, minus Claims paid, if claims over a stated period of time do not exceed a fixed percentage of the Premiums paid.3
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| Revenue |
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The same as Premium.
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| Revenues |
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The amounts earned from a company's sales of products and services to its customers.
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| RHU |
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Registered Health Underwriter.
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| Rider |
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An Attachment, amendment or endorsement to an insurance Policy.
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| Risk |
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For a Health Insurance (HI) company, risk is the chance of loss, the degree of probability of loss or the amount of possible loss. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications' side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice. For example, an individual increases his or her risk of getting cancer if he or she chooses to smoke cigarettes.
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| Risk Analysis |
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The process of determining what Benefits to offer and Premium to charge a particular group.
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| Risk Pool |
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See Pool.
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| Risk-Adjustment |
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The statistical adjustment of Outcomes Measures to account for risk factors that are independent of the Quality of care provided and beyond the control of the plan or Provider, such as the patient's gender and age, the seriousness of the patient's illness, and any other illnesses the patient might have. Also known as Case-Mix Adjustment.
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| RVS |
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See Relative Value Scale (RVS).
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| RX |
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A symbol for "Prescription Drugs".
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