Health Insurance Glossary R-Z

For this health insurance glossary, please note that definitions of terms may vary among insurance companies and across states.

R

Rating Process: The underwriting process by which risk is assessed and a premium or rate for an insured group or person is determined. Factors considered in the rating process include age, sex, type of industry, benefits and administrative costs.

Referral: The process by which a patient under a managed care health insurance plan is authorized by the primary care physician to a see a specialist for the diagnosis or treatment of a specific condition.

Registered Nurse (RN): A licensed professional nurse with a four-year nursing degree, trained to provide all levels of nursing care including the administration of medication.

Renewal: Continuance of member coverage under a health insurance plan beyond the original period of the contract. At the end of each benefit year, a plan member is usually invited to renew coverage.

Renewal Date: The date on which a member's health insurance plan benefit year renews.

Respite Care: A benefit made available for family caregiver members of a patient to provide the patient's primary caretaker with a break or respite from caring for the patient. Respite care may be provided for the patient in either the home or a nursing home setting.

Rescission: Termination of an insurance contract by the insurer on the grounds of misstatement by the insured on the application. The action of rescission must take place within the contestable period or time limit on certain defenses, but it takes effect on the date of issuance of the policy, thus voiding the contract from its inception.

Rider: An amendment or modification to an insurance contract.

S

Schedule C: The federal tax form used to report business income or business losses. A copy of this form may be required from an employer when applying for a group health insurance plan.

Schedule K-1: The federal tax form used to report a business partner's share of the income, credits and deductions from a business organized as a partnership or s-corporation. A copy of this form may be required from en employer when applying for a group health insurance plan.

Second Surgical Opinion: A second opinion from a qualified physician or specialist that may be required by an insurer before extending coverage for certain surgical procedures.

Secondary Care: Medical care rendered by a specialist rather than a primary care physician.

Secondary Coverage: The health insurance plan that provides payment on claims after the primary coverage when a patient has more than one insurance plan.

Section 125 Plan: A plan which provides flexible benefits and qualifies under the IRS code which allows employee contributions to be deducted on a pre-tax basis.

Self-funded Health Insurance Plan: A health insurance plan that is funded by an employer, not through a health insurance company. A health insurance company may handle the administration of such a plan under contract with the employer.

Service Area: The geographic area in which a health insurance plan benefits are made available. Some health insurance plans will not provide coverage outside of a plan service area.

Short-term Health Plans: Short-term health insurance plans are similar to individual and family health plans, except coverage typically extends for less than 12 months and benefits are limited not comprehensive.

Skilled Nursing Care: Intensive care usually administered around the clock and rendered by or under the supervision of a Registered Nurse. Usually prescribed by a doctor and on an inpatient basis at a hospital or skilled nursing facility.

Specialist: A physician who does not serve as a primary care physician and who specializes in a specific medical field.

Standard Industrial Classification (SIC) Codes: Numeric codes used to describe or classify businesses based upon the products or services they provide. Usually required of an employer in application for group health insurance coverage. This code provides the insurance company with information about the kind of work employees are likely to perform and may be used to assess risk.

Subrogation: The legal analysis process by which a health insurance company determines whether medical bills should be paid for by the health insurance company itself or whether another insurer or third party may be liable.

T

Temporary Partial Disability: Term is used to describe the condition of a person who due to injury is unable to work at full capacity but who is able to work at reduced efficiency and is expected to fully recover.

Temporary Total Disability: Term that describes the condition of a person who due to injury is unable to work, but who is expected to fully recover.

Tertiary Care: Term used to describe services rendered by specialized providers such as intensive care units, neurologists, neurosurgeons and thoracic surgeons. Services frequently require highly sophisticated equipment and facilities.

Terminal Illness: Term is used to describe an illness with which the person is not expected to live beyond six months.

Travel Accident Policy: A limited contract that covers only accidents while an insured is traveling, usually on a commercial carrier.

Treatment Facility: Any facility, residential or non-residential, which is authorized to provide treatment for mental illness or substance abuse.

Triage: A process of classifying and prioritizing sick or injured patients according to the severity of their conditions in order to ensure that medical facilities and staff are most effectively utilized.

U

Underwriting: The process by which an insurer assesses risk, assigns premium and determines whether it will accept an application for insurance based upon contemplated risks and projection of the estimated premium.

Uniform Billing Code of 1992 (UB-92): The Uniform Billing Code of 1992 that set industry-wide standards for medical billing practices.

Usual, Customary and Reasonable (UCR) Charge: Refers to the standard or most common charge for a particular medical service when rendered in a particular geographic area. Often employed in determining Medicare payment amounts.

Utilization: The frequency with which group members use benefits associated with a particular health insurance plan or healthcare program.

Utilization Management/Review: Review function of healthcare professionals who work with health insurance plans to determine if a patient's use of healthcare services was medically necessary, appropriate, and within the guidelines of standard medical practice. May also be referred to as Medical Review.

V

Vision Care Coverage: An insurance plan typically offered only on a group basis which covers routine eye examinations and which may also cover all or part of the costs associated with contact lenses or eyeglasses.

W

W-2: Federal tax form used to report an employee's wages and taxes.

Waiting Period: A period of time (often up to 12 months) beginning with a patient’s effective date during which a health insurance plan does not provide benefits for pre-existing conditions. This period may be reduced or waived based on any continuous prior health care coverage the patient had before applying for new health insurance plan.

Waiver: An insurance policy addendum under which a member agrees to waive coverage for specific pre-existing conditions or for specific future conditions and/or time. Also called Exclusion Endorsement.

Waiver of Premium: Allows a member to maintain health insurance coverage in full force without payment of premium, typically only granted in cases of permanent and total disability.

Well-Baby/Well-Child Care: Regularly scheduled, preventive care services, including immunizations, provided to covered children up to an age specified by a health insurance company or mandated by a government agency.

Well-Woman Care: Refers to preventive care services for women, such as mammograms and pap smears.

X

X-Ray Benefits: Typically any diagnostic X-ray services performed in support of basic health services. X-ray services typically include basic outpatient skeletal or other plain film x-ray, outpatient ultrasound, GI series, MRI, and CT scan. Prostate cancer screening, mammograms, and pap smears may be covered by Lab/X-Ray benefit, or they may be covered by Periodic OB-GYN benefit or Preventative Care benefits. Typically, dental x-rays are not included in Lab/X-ray benefits.

Y

Z

For a term beginning with A or B, go to Glossary A-B;

For a term beginning with C, D, E or F, go to Glossary C-F;

For a term beginning with G, H, I, J, K, L or M go to Glossary G-M;

For a term beginning with N, O, P or Q go to Glossary N-Q;