Health / Health Insurance Glossary

Recredentialing: Reexamination by an MCO of the qualifications of a provider and verification that the provider still meets the standards for participation in the network.

Relative Value Scale (RVS): 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 . . . View Full Definition

Renewal Underwriting: 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 . . . View Full Definition

Report Card: A set of performance measures applied uniformly to different health plans or providers.

Rescission: is a controversial insurance industry practice that has come under fire as an unfair tactic used to deny coverage to policy holders. If you've been a victim of rescission, your insurance com . . . View Full Definition

Reserves: Estimates of money that an insurer needs to pay future business obligations.

Resource-Based Relative Value Scale (RBRVS): 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 physicia . . . View Full Definition

Retrospective Authorization: Authorization to deliver healthcare service that is granted after service has been rendered.

Revenues: The amounts earned from a company's sales of products and services to its customers.

Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).

Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgi . . . View Full Definition

Risk-Adjustment: 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 p . . . View Full Definition

Second Opinion: It is a medical opinion provided by a second physician or medical expert, when one physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain . . . View Full Definition

Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an opinion provided by a second physician, when one physician recommends surgery to an individual.

Section 1115 Waivers: Waivers that states could obtain from the federal government which allowed them to set up managed care demonstration projects.

Section 1915(B) Waivers: Waivers that states could obtain from the federal government that allowed them to restrict a Medicaid beneficiary's choice of providers by using a primary care case manager or other arrangement.

Self-Funded Plan: A health plan under which an employer or other group sponsor, rather than an MCO or insurance company, is financially responsible for paying plan expenses, including claims made by group pla . . . View Full Definition

Senior Market: A market segment that is comprised largely of persons over age 65 who are eligible for Medicare benefits.

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