Glossary

R

Treatment of disease by x-ray, radium, cobalt or high energy particle sources.

The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).

A termination of coverage with an effective date that is retroactive.

A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

For HMO members, referral care is the care you receive from a network provider other than your primary care doctor. Your primary care doctor must first give you a referral for this care or the plan may not pay for it. Note that women may visit their OB/GYN without a referral.

Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

A review done after services are completed (usually as part of a claim or appeal), that ensures that the care given was medically necessary.

A provision added to a contract whereby the scope of its coverage is increased or decreased.