Glossary (R)

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rating

The method used to determine the cost of premiums.

readmission

A repeat admission, after discharge for the same diagnosis or condition as the original admission, that is considered part of the first admission when it occurs within a specified period.

recertification

A request for additional hospital days beyond the originally approved length of stay.

reconsideration

A critical review of a claim that has been processed when the member or a representative is dissatisfied with the original decision.

referral

The recommendation by a primary care physician for a member to receive specialized care from a practitioner or facility.

regular business

Obsolete term once used to distinguish BCBSM product lines from government programs, such as Medicare.

reimbursement

The process by which health care providers are paid for their services.

reinsurance

A type of insurance protection, such as stop loss, to cover extraordinary losses.

relative value scale

A financing tool, the RVS uses relative value units to reflect the complexity and intensity of services performed in various medical and surgical specialties. Units are multiplied by a conversion factor to compute the appropriate payment level for any given service.

report card

Information developed by consumer-focused organizations about the cost and quality of health services of a plan and its practitioners.

reserves

Money held by an insurance company or health plan to cover extra or unexpected liabilities. Most states require carriers to hold a specified minimum level of reserves.

resource-based relative value scale

A methodology introduced by the Centers for Medicare and Medicaid Services to create the Medicare fee schedule, the RBRVS incorporates factors such as the amount of time and resources expended in treating patients, overhead costs and geographical differences.

respite care

Care intended to provide temporary relief to a full-time caregiver.

retrospective review

The evaluation of medical necessity and appropriate billing for services that have already been rendered.

revenue code

A three-character code that identifies facility services provided.

rider

A legal document that amends a certificate by increasing, limiting, deleting or clarifying the scope of coverage.

risk adjustment

  1. A method used to predict resource consumption.
  2. A method used to compare and monitor clinical outcomes of care.

risk factors

Conditions that determine how much chance of loss there is in insuring an individual or a group.

risk management

A program to identify and take action against risks that might lead to injury or loss.

risk pool

Money held in reserve for provider payments.

risk sharing

The distribution of financial risk among parties furnishing a service.

rural health clinic

A public or private hospital, clinic or physician practice licensed by the state to provide preventive services that complies with the Rural Health Clinics Act by being located in a medically underserved area and using physician assistants or nurse practitioners.

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