Rating Process

Steps used to determine premium rate for particular group based on amount of risk that group presents. Generally factored into the rating process are age, sex, type of industry, benefits, and administrative costs.

Reasonable and Customary Charges

Charge for medical services referring to amount approved by the Medicare Carrier for payment. Customary charges are defined as those most often made by a provider for services rendered in that particular area.

Recidivism

How often a patient returns to an inpatient hospital status for the same reason.

Recurring Clause

Health Insurance policy provision defining duration of time during which recurrence of a condition is considered a continuation of a prior period of disability or confinement.

Referral

Physician or other health plan provider receives permission to consult another physician or hospital.

Referral Provider

Person or provider to whom a provider has referred a member of the plan.

Rehabilitation Clause

Clause in a Health Insurance policy intended to assist the disabled policyholder in vocational rehabilitation.

Relative Value Schedule

Surgical schedule basically comparing the value of one surgical procedure to another and establishing the surgical fee to be paid.

Relative Value Unit

Used in place of dollar amounts in a surgical schedule. This number is multiplied by a conversion factor to arrive at the surgical benefit to be paid.

Residual Disability

Form of disability defined as partial disability when an insured returns to work immediately following a period of total disability.

Residual Income

Clause used with disability income policies providing benefits to be paid when the insured can do some but not all of their normal duties.

Respite Care

Normally associated with Hospice care, a benefit to family members of a patient when the family is provided with a break from caring for the patient. Patient is confined to a nursing facility for needed care for a short period of time.

Restoration of Benefits

Provision in Major Medical Plans restoring a person's lifetime maximum benefit amount in small increments after a claim has been paid. Only a small amount ($1,000 to $3,000) usually may be restored annually.

Retention

Portion of premium used by the insurance company for administrative costs.

Return of Premium

Rider or provision in Health Insurance policy agreeing to pay 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.

Risk Analysis

Process of determining benefits to be offered and premium to charge a particular group.