Type of audit of hospital patient records that occurs continually to verify charges in which blind charts are pulled and examined to maintain quality control. Also see audit by request and defense audit .

Group of cases selected for study, which is drawn indiscriminately from the universe of cases by a statistically valid method.
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Sample selected or assigned in such a way that all members of the population from which the sample was drawn were equally likely to have been selected.Representative Sample : Sample that corresponds to or matches the population from which it was drawn, with respect to the percentage of cases having characteristics likely to be important for the purpose under study.Stratified Random Sampling ; Sampling technique in which a population is divided into sub-classification or strata according to certain key variables (age, gender, etc.) such that each case appears in only one sub-group. Cases are then selected at random from within each sub-group, either in proportion to that sub-group’s distribution in the population or in equal numbers per sub-group in order to increase the representative aspects of the sample.Sanction Limitation and Exclusion Clause : No reinsurer shall be deemed to provide cover and no reinsurer shall be liable to pay any claim, or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose that (re)insurer to any sanction, prohibition, or restriction under United Nations resolution or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America, 11.08.2010 HC 2010/014. Effect to this clause prohibits the provisions of marine insurance including both Cargo and Hull prohibits insurance, to pay claims or to provide any other benefits if so doing would be a breach of such sanctions.

MEDICAL,USA: Establishing premium rates for an insurance company’s policies by using a formula. In life insurance, important factors considered are mortality rates, interest rates, and loading.
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The process of developing pricing structures for insurance.
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A manual containing rates for various coverage, information and instructions for field underwriting, insurer’s rules for the guidance of agents and similar other risk acceptance guidelines.
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A manual that contains the rates for coverages, and can contain other items such as guidelines to field underwriting, agent guidelines, and cash forfeiture values.

System used to bill for group health insurance based on type of contract or age/sex breaks.

System of comparing costs of life insurance policies by using the following formula: 1. Determine pure cost of protection (mortality expectation). 2. Calculate amount of dividends paid. 3. Subtract the pure cost of protection plus dividends from the gross premiums paid into the policy (savings element). 4. Rate of return equals the interest rate at which the savings element must be accumulated to equal the cash value of the policy at a future specific time period. Also called Linton yield method .

To ask for a set of insurance rates that are based on a specific list of benefits.

System in health insurance for establishing premiums so that an insurance company’s premium varies by not more than a fixed amount from other premiums for individuals in the same premium class within a certain geographical region.

Advance evaluation of a health care facility’s financial data by a government or private agency to determine the reasonableness of the hospital fees and assess a possible increase in the fees.

1. System used to contain health care costs in which the government sets payment fees for all insurance payers for categories of medical services. 2. In the Medicare program, to determine and establish the cost of medical professional services provided to a patient by using historical cost data reported by providers.

If a specific account’s actual experience at the close of an insurance contract period results in excess funds, these can be applied toward the account’s rate for the next year, which helps offset the rate increase.