System of establishing rates in which the current year’s insurance premium is calculated to give the actual current year’s loss experience (usage of health care). Gains may be returned by rate credits or increase of benefits or cash, and deficiencies are obtained through a recovery factor in the rates or cash. Also called retrospective rate derivation .

Payment made to a provider by the insurance company for actual costs or charges incurred by the insured during the previous time period. Also called retroactive reimbursement .

Method that sets the payment rate for hospital services after services have been provided.

1. In external auditing, process of going over financial documents after billing an insurance carrier to determine documentation deficiencies and errors. Also called retrospective payment audit . 2. In utilization review, evaluation of medical services given to a patient to make sure the insurance claims are paid for appropriate care (i.e., medical necessity, quality of care, physicians’ practice patterns, hospitals’ average length of stay, and reasonableness of services given).

In reference to Centers for Medicare and Medicaid Services (CMS) data, a situation that occurs when a requestor from the same or different organization requests permission to use CMS data already obtained for a prior approved project.

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

Four-digit number in the hospital’s chargemaster that identifies a specific accommodation, ancillary service, or billing calculation related to the claim being submitted. These payment codes are inserted in Field 42 in ascending order on the Uniform Bill (UB-04) inpatient hospital billing claim form. Billing guidelines for revenue codes are extensive, so refer to the UB-04 manual for detailed information. Revenue codes are important because some managed care plans base payment on diagnosis, procedure, and revenue codes. All revenue codes from 001 to 999 must be preceded with a “0.” The leading “0” is added automatically for electronic claims. Basic revenue codes end in “0.” Detailed revenue codes end in 1 through 9. Do not repeat revenue codes on the same claim except when required by field or for coding more than one HCPCS code for the same revenue code item.

Proportion of a medical practice’s total income allocated for a specific type of expense (e.g., practice expense profit share is that proportion of income used to pay for practice expense).