Term Definition
RAILROAD RETIREMENT

A federal insurance program similar to Social Security designed for workers in the railroad industry. The provisions of the Railroad Retirement Act provide for a system of coordination and financial interchange between the Railroad Retirement program and the Social Security program.

RANDOM SAMPLE

A random sample is a group selected for study, which is drawn at random from the universe of cases by a statistically valid method.

REAL-WAGE DIFFERENTIAL

The difference between the percentage increases before rounding in (1) the average annual wage in covered employment, and (2) the average annual CPI.

REASONABLE COST

FIs and carriers use CMS guidelines to determine reasonable costs incurred by individual providers in furnishing covered services to enrollees. Reasonable cost is based on the actual cost of providing such services, including direct and indirect cost of providers and excluding any costs that are unnecessary in the efficient delivery of services covered by the program.

REASONABLE-COST BASIS

The calculation to determine the reasonable cost incurred by individual providers when furnishing covered services to beneficiaries. The reasonable cost is based on the actual cost of providing such services, including direct and indirect costs of providers, and excluding any costs that are unnecessary in the efficient delivery of services covered by a health insurance program.

RECIPIENT

An individual covered by the Medicaid program, however, now referred to as a beneficiary.

RECOUPMENT

The recovery by Medicare of any Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.

REFERRAL

A written OK from your primary care doctor for you to see a specialist or get certain services. In many Medicare Managed Care Plans, you need to get a referral before you can get care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for your care.

REFERRAL

A plan may restrict certain health care services to an enrollee unless the enrollee receives a referral from a plan-approved caregiver, on paper, referring them to a specific place/person for the service. Generally, a referral is defined as an actual document obtained from a provider in order for the beneficiary to receive additional services.

REFERRAL SERVICES

Means any specialty, inpatient, outpatient or laboratory services that are ordered or arranged, but not furnished directly. Certain situations may exist that should be considered referral services for purposes of determining if a physician/group is at substantial financial risk. For example, an MCO may require a physician group/physician to authorize "retroactive" referrals for emergency care received outside the MCO's network. If the physician group/physician's payment from the MCO can be affected by the utilization of emergency care, such as a bonus if emergency referrals are low, then these emergency services are considered referral services and need to be included in the calculation of substantial financial risk. Also, if a physician group contracts with an individual physician or another group to provide services that the initial group cannot provide itself, any services referred to the contracted physician group/physician should be considered referral services.

REGENSTRIEF INSTITUTE

A research foundation for improving health care by optimizing the capture, analysis, content, and delivery of health care information. Regenstrief maintains the LOINC coding system that is being considered for use as part of the HIPAA claim attachments standard.

REGIONAL HOME HEALTH INTERMEDIARY (RHHI)

A private company that contracts with Medicare to pay home health bills and check on the quality of home health care.

REGIONAL OFFICE

CMS has 10 Ros that work closely together with Medicare contractors in their assigned geographical areas on a day-to-day basis. Four of these Ros monitor Network contractor performance, negotiate contractor budgets, distribute administrative monies to contractors, work with contractors when corrective actions are needed, and provide a variety of other liaison services to the contractors in their respective regions.

REHABILITATION

Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.

REHABILITATION (AS DISTINGUISHED FROM VOCATIONAL REHABILITATION)

A restorative process through which an individual with ESRD develops and maintains self-sufficient functioning consistent with his/her capability.

REJECT STATUS

The encounter data did not pass the "front-end" edit process. M+CO needs to correct the data and resubmit.

RENAL TRANSPLANT CENTER

A hospital unit that is approved to furnish transplantation and other medical and surgical specialty services directly for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.

REOPENING

An action taken, after all appeal rights are exhausted, to re-examine or question the correctness of a determination, a decision, or cost report otherwise final.

REPORT CARD

Is a way to check up on the quality of care delivered by health plans. Report cards provide information on how well a health plan treats its members, keeps them healthy, and gives access to needed care. Report cards can be published by States, private health organizations, consumer groups, or health plans.

REQUESTOR

An entity who formally requests access to CMS data.

RERELEASE

When a requestor formally requests permission to rerelease CMS data that has been formatted into statistical or aggregated information by the recipient. CMS is responsible for reviewing the files/reports to ensure that they contain no data elements or combination of data elements that could allow for the deduction of the identity of the Medicare beneficiary or a physician and that the level of cell size aggregation meets the stated requirement.

RESEARCH DATA ASSISTANCE CENTER

A CMS contractor that provides free assistance to academic and non-profit
research interested in using Medicare and Medicaid data for research.

RESEARCH PROTOCOL

A document that outlines a strong research design, which clearly states the
objectives, background, methods and the significance of the study being
proposed.

RESERVE DAYS

(See Lifetime Reserve Days.)

RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY

A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

RESIDUAL FACTORS

Factors other than price, including volume of services, intensity of services, and age/sex changes.

RESOURCE-BASED RELATIVE VALUE SCALE

A scale of national uniform relative values for all physicians' services. The relative value of each service must be the sum of relative value units representing physicians' work, practice expenses net of malpractice expenses, and the cost of professional liability insurance.

RESPITE CARE

Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off.

RESTRAINTS

Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.

REUSE

Reuse of CMS data occurs when a requestor, from the same or different organization requests permission to use CMS data already obtained for a prior approved project.

REVENUE

The recognition of income earned and the use of appropriated capital from the rendering of services in the current period.

REVENUE CODE

Payment codes for services or items in FL 42 of the UB-92 found in Medicare and/or NUBC (National Uniform Billing Committee) manuals (42X, 43X, etc.)

REVIEW OF CLAIMS

Using information on a claim or other information requested to support the services billed, to make a determination.

RIGHTS OF INDIVIDUALS
  • Receive notice of information practices;
  • See and copy own records;
  • Request corrections; Obtain accounting of disclosures;
  • Request restrictions and confidential communications;
  • File complaints
RISK ADJUSTMENT

The way that payments to health plans are changed to take into account a person's health status.

RISK-BASED HEALTH MAINTENANCE ORGANIZATION/COMPETITIVE MEDICAL PLAN

A type of managed care organization. After any applicable deductible or co-payment, all of an enrollee/member's medical care costs are paid for in return for a monthly premium. However, due to the "lock-in" provision, all of the enrollee/member's services (except for out-of-area emergency services) must be arranged for by the risk-HMO. Should the Medicare enrollee/member choose to obtain service not arranged for by the plan, he/she will be liable for the costs. Neither the HMO nor the Medicare program will pay for services from providers that are not part of the HMO's health care system/network.

ROUTINE USE

The purposes identifiable data can be collected and the authority to release
identifiable data.

RURAL HEALTH CLINIC

An outpatient facility that is primarily engaged in furnishing physicians' and other medical and health services and that meets other requirements designated to ensure the health and safety of individuals served by the clinic. The clinic must be located in a medically under-served area that is not urbanized as defined by the U.S. Bureau of Census.


*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.