REASONABLE AND CUSTOMARY (R &C) CHARGE:
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. “Reasonable and Customary (R&C) Charge” essentially means the same thing as “Usual and Customary (U&C) Charge.”
An OK from the primary care physician for the patient to see a specialist or get certain services. In many HMO plans, the insured person needs to get a referral before they get care from anyone except the primary care physician. If the referral is not received, the HMO may cover resulting expenses.
A continuation of an insurance policy on revised terms, such as adjusted health insurance rates.
For a health insurance company, risk is the chance of loss, the degree of probability of loss or the amount of possible loss. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications’ side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice. For example, an individual increases his or her risk of getting cancer if he or she chooses to smoke cigarettes.