Provision in an insurance policy that reduces the level of life insurance to another amount of coverage. This situation can occur when the insured reaches a specific age or retires.

Inactive membership in an insurance plan that is reestablished using the same subscriber identification number and may be in the same group or a new group.

Diagnostic laboratory tests performed on samples that are referred to the hospital laboratory.

1. Transfer of the total or specific care of a patient from one physician to another. 2. In managed care, a request by the primary care physician for authorization for a member to receive care from a specialist or hospital or get certain services. In some managed care plans, a member may need an approval from the primary care physician to a specialist for insurance coverage. 3. Document obtained from a provider or plan-approved caregiver so that a plan enrollee may receive additional medical services from a specific place/person.

Verbal or formal written document that gives approval to a managed care plan member to obtain medical services outside of the network of participating providers (e.g., primary care physician approves a plan member to see a specialist).

Telephone service staffed by nonclinical personnel that directs patients to approved hospital facilities and physicians and may also perform triage. Managed care plans use these call centers to communicate with patients and providers and sometimes to precertify or preapprove care. Usually the center has a toll-free 800 number for easy access and no charge to health plan members. Also known as call center, 24-hour certification, or triage .

Funds put aside for noncapitated medical services given by a primary care physician (PCP), referral specialist, or emergency services.

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 (see Box R-1 ).Box R-1REFERRAL SERVICESExample 1: A managed care organization (MCO) may require a physician group/physician to authorize retroactive referral for emergency care received outside the MCO’s network. If the physician group/physician’s payment from the MCO can be affected by the use of emergency care such as a bonus if emergency referrals are low, then these emergency services are considered services and must be included in the calculation of substantial financial risk.Example 2: 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.

Patient who is sent from a physician to a diagnostic or therapeutic outpatient facility or to a specific hospital outpatient department for the diagnosis and treatment of an illness or injury.