Insurance agreement between a reinsurer and a ceding company that states the way the insurance on many different risks is to be shared.

Insurance claim encounter data that did not pass the front-end edit process and the data need to be corrected and resubmitted.

Insurance claim submitted to insurance carrier that is discarded by the system due to a technical error (omission of erroneous information) or because it does not follow Medicare instructions. It is returned to the provider for correction or change so that it may be processed properly for payment. It cannot be appealed. Also called soft denial .

Clinical cases that have medical procedures with the same diagnosis, same operative area, and same indication.

Provision in some policies that limits the amount of benefits in which the insurance company will participate when the total amount of disability benefits from all insurers is beyond the insured’s usual earnings. Also known as participation limit .
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In disability insurance, a provision that reduced payment to the proportion of policy benefits that the insured’s earnings at the time of disability (or average earnings for two years prior to disability) bear to total disability benefits under all policies, also called the average earnings clause.

Code that identifies the gender and association of a member to the subscriber.

Compiled list of particular rating or rank of medical services based on the intensity of the procedure performed. Each professional service listed by procedure code is given a relative value unit (RVU) and that is multiplied by a dollar conversion factor to show the monetary value for each procedure. The study becomes a fee schedule when dollar conversion factors are applied. RVS is published as a guide book to show the relative value of one procedure over another. Also called relative value scale (RVS) .

Monetary value assigned to each service based on the amount of physician work, practice expenses, and the cost of professional liability insurance. These three RVUs are then adjusted according to geographical area and used in a formula to determine Medicare fees.