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Glossary of Health Insurance Terms

As you explore our site, you may come across an unfamiliar word or term. We've developed a glossary of health care terms we hope will help you.

Select one of the following letters to take you to the part of the alphabet that applies.

R

RA - See "Remittance Advice."

RBRVS - See "Resource Based Relative Value Study."

Recredentialing - The process performed every three years after a provider has been credentialed by BCBSKS. This is sometimes referred to as "Re-Cred". See "Credentialing."

Referral - If a PCP determines a patient has a condition that requires the attention of a specialist, the PCP completes a form, outlining the care to be given and sends it and the patient to the specialist.

Referral Specialist -RS - A Blue Select provider who has signed an agreement to extend services to patients. These providers are not PCP and the scope of their practice or business is limited to a type of service or specific body system-s.

Referring Provider - The doctor who has the responsibility for the care of the patient and who has requested that another doctor or health care professional see the patient for a certain condition, system, diagnosis or complaint.

Refunds - Requests for money that are made of a provider or patient when a claim has been processed in error. Another form of refund is when a patient has overpaid a contracting provider coinsurance and deductible amounts and the provider is required to pay the patient the overpayment.

Rejected Claim/Service - A denied request for payment. These denials may be due to various reasons. Some of the more common ones are duplicate of an already processed claim/service, non-covered service-s or another insurance carrier is responsible for processing the claim/service first.

Relationship to the Insured -RTI - This refers to the spouse and dependent children of the member/member -policyholder. The identifier codes are as follows:

  • 1 = self
  • 2 = spouse
  • 3 = child

Relative Value Unit -RVU - The numeric assignment to a procedure code that indicates the value of the service.

Remittance Advice -RA - A computer generated report that explains the processing of a claim. There is usually more than one claim on a RA and can list many different patients. RAs are used by providers to post their accounts receivable.

Remote Job Entry -RJE - Refers to the procedure by which claims are entered into a computer at the provider's office and transferred at a specific time via the telephone wires.

Rep - BCBSKS PR field staff member who provides a liaison between the health care community and BCBSKS; or the Marketing staff member who sells BCBSKS health insurance and provides a liaison between employer groups and non-group patients and BCBSKS. This can also be the PR field staff member who provides a liaison between the hospitals and BCBSKS, these staff are also referred to as provider consultants.

Request for Payment - A claim form, usually the HCFA-1500 -12-90 or the UB92.

Research-Urgent - A drug, device, medical treatment or procedure that may be covered -even though otherwise excluded by the patient's contract as experimental or investigational providing the specified criteria outlined in the patient's contract is met.

Resource Based Relative Value Study -RBRVS - A methodology of reimbursement using points for each procedure and a conversion factor to establish an allowance for a given procedure code. BCBSKS does not utilize this system solely to establish MAPS.

Rest Cures - Treatment or services which could be rendered safely and reasonably by self, family, or other care givers who are not health professionals.

Retrospective Review - The procedure by which a given claim is re-adjudicated to ensure correct processing has taken place before the appeals process begins. This request for retrospective review must be submitted to CSC within 120 days of the original processing date.

Re-Verification of Credentials - The interim procedure that is used to determine the continued validity of a managed care provider's credentials. This process takes place after credentialing and before re-credentialing; or between re-credentialing processes - which is every three years when there is just cause.

Rider - An amendment to a patient contract which may extend, reduce or exclude the benefits of the original contract. The provisions of a rider are stated specifically on a separate document that is attached to the patient's basic contract.

Ridered Condition - An illness or condition, otherwise eligible, for which any type of treatment is excluded from BCBSKS coverage.

RJE - See "Remote Job Entry."

RPT - Registered Physical Therapist.

RS - See "Referral Specialist."

RTI - See "Relationship to the Insured."

RVU - See "Relative Value Units."