Core set of screening and assessment elements of the Resident Assessment Instrument (RAI). This assessment system provides a comprehensive, accurate, standardized, reproducible assessment of each long-term care facility resident’s functional capabilities and helps staff to identify health problems. This assessment is performed on every resident in a Medicare and/or Medicaid-certified long-term care facility including private pay.

Medical record, electronic or paper, that contains the patient’s lifetime health care history, diagnoses, treatments, medications, and tests.

Federal act that provides benefits for private and public employees who perform maritime work nationwide.

The automated diagnosis-related group (DRG) grouper process (computer software program that assigns DRGs) that searches all listed diagnoses for the presence of any comorbid condition or complication or searching all procedures for operating room procedures or other specific procedures.

Change in a person’s ability to perform physical or other activities as compared with his or her condition before the injury after the condition has become stable.

MEDICAL,USA: 1. The proportion between the cost to deliver health care and the amount of money taken in by the managed care plan. 2. The relative amount of insurance claims incurred to insurance premium monies received. An indicator used by insurance companies to measure the amount of benefits returned to policyholders. The formula for obtaining the ratio is incurred claims plus expenses divided by premiums. Low loss ratio indicates that the premiums collected were more than necessary to fund the actual claims. High loss ratio shows that claims exceeded the premiums for the given time period. Also known as incurred claims loss ratio, medical loss ratio (MLR), medical cost ratio , or paid claims loss ratio .
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A ratio determined by dividing the losses by the premiums paid. The losses can be either losses incurred or losses paid, and the premiums can be earned premiums or written premiums.
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Fraction calculated by dividing the amount of insured losses by the amount of Insurance premium, expressed as a percentage of the premiums. Various bases are used in calculating the loss ratio, which may apply to an Insurer’s entire operations, a particular type of Insurance, or a particular insured’s losses.
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REINSURANCE: Losses incurred expressed as a percentage of earned premiums.
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REINSURANCE: Proportionate relationship of incurred losses to earned premiums expressed as a percentage.
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US: Proportionate relationship of incurred losses to earned premiums expressed as a percentage. If, for example, a firm pays $100,000 of premium for workers compensation insurance in a given year, and its insurer pays and reserves $50,000 in claims, the firm’s loss ratio is 50 percent ($50,000 incurred losses/$100,000 earned premiums).
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US: The percent which losses bear to premiums for a given period. The ratio of claims to premiums. It may be calculated in several different ways, using paid premiums or earned premiums, and using paid claims with or without changes in claim reserves and with or without changes in active life reserves.
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UK: the proportion of claims paid or payable to the premiums earned or written.
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The ratio of incurred losses including loss adjustment expenses to earned premiums. Loss ratios can be calculated on an accident year, calendar year, or underwriting year basis.
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UK: The ratio of losses paid and outstanding to premiums. The lower the loss ratio the more satisfactory the outcome and the greater the amount available for commissions, administration costs and profit.

Insurance claim that cannot be located after sending it to an insurer.

In workers’ compensation cases, this is a claim filed for the time lost from work as a result of an industrial injury or occupational illness.