Lesson 7 Flashcards
What does COB stand for
Coordination of Benefits
7.1.1 Outline 4 steps a plan administrator or claims analyst typically takes to process a claim
1) Obtains or reviews information regarding the event for which the claim was submitted
2) Relates this info to the provisions and terms of the plan
3) Calculates the amount of benefits payable to the claimant
4) Processes and delivers payment of benefits to the plan member or beneficiary
7.1.2 Outline 7 pieces of information a claims analyst must confirm in order to process a claim
1) That the group contract was in force at the time the loss was incurred
2) That the member/dependent was insured at the time
3) Proof of loss was provided within the required time frame
4) Information to determine liability, type of benefit, and amount
5) Who the benefit is paid to
6) Whether the insurer is responsible for the admin aspects of payment
7) Payment options that apply to the claim
7.1.3 Explain why the claims analysts must keep accurate and current information on payments and claims relating to each member and dependent
To ensure claims are applied to the right benefits plan
To ensure limitations to claims are kept (frequency, amount)
In case a plan member sues, disagreeing with the adjudication
Claims information is also part of financial information provided by the plan sponsor at intervals and helps the sponsor determine plan design issues
7.2.1 Describe the documentation necessary to process a death benefit claim
- Completed life insurance form and proof of death
If submitted more than 12 months after death a coroner’s report may be required by some insurers, though some have no time limit.
For AD&D proof that the loss was the result of an accident.
In cases of disappearance the claim is only paid once declared legally dead
7.2.2 Describe the facility of payment provision in a group insurance contract
Allows a portion to be paid to an individual other than the beneficiary who has paid expenses related to the funeral or illness prior to death.
Amount is set out in contract or may be limited to reasonable expenses
7.2.3 Identify who gets the benefit if both the member and beneficiary die in the same accident (Common disaster)
If there is no evidence of who died first the insured is deemed to have survived the beneficiary and it goes to the insured’s estate or contingent bene
If the beneficiary survived the plan member the benefit is payable to the beneficiary’s estate. In some cases the beneficiary must survive the plan member for a certain number of days
7.2.4.a when are AD&D life insurance benefits payable
With AD&D death benefits are typically payable if death occurs within 12 months of the accident
7.2.4.b What makes creditor’s life insurance different from regular group life
Under group contract or creditor’s life the insured borrower doesn’t name a beneficiary as benefits are payable to the financial institution.
7.2.4.c Who is the beneficiary of dependent life insurance
The insured member - no other can be designated
7.3.1.a List three ways that group health care claims differ from group life claims
1) volume is much higher
2) here is a higher proportion of ineligible claims
3) Determining the amount is more complex (based on actual loss)
4) Rejection of duplicate claims so it’s not paid twice
7.3.4 Describe the documentation necessary to process health care claims and list 6 things that need to be on the bill
A completed claim form and written proof of loss must be provided within 12-18 months of the loss
Service provider information must be provided, the bill is usually acceptable if it includes:
1) full name of mbr
2) date of service
3) description of medical condition if required
4) description of service/product including itemized costs
5) name of the provider
6) Attending physician’s referral or description of service if provided by other than physician
7.3.5 Outline the documentation necessary to process drugs claims
The TPA or insurer must receive a description of the drug, proof it was prescribed. The pharmacy receipt may suffice if it includes:
1) Full name of the covered individual
2) DIN and the name of the drug
3) Name and practitioner who prescribed the drug
4) Price charged by the pharmacy for the drug
5) date of purchase
7.3.6 Explain how the PDD plans are processed
In real time if pharmacist is electronically linked to the provider
Can instantly verify mbr and benefit eligibility as well as deductible.
Some systems can alert pharmacists to drug utilization concerns such as allergies or other drugs being taken that may interact
What does PDD stand for
Pay direct drugs
7.4.1 Describe the documentation necessary to process dental claims
Proof of loss must be submitted within 12-18 months of loss and not more than 3 months after the date that group coverage for a plan member terminates.
For routine procedures the following are required:
1) Treatment provided and procedure code
2) Dentist or qualified practitioner who provided treatment
3) Date the treatment was provided
7.4.1 For dental procedures with multiple appointments what date are dentists advised to use (give 2 examples of procedures)
Dentists are advised to use the date of the final visit for eligibility
Some procedures that require multiple visits are bridgework and the installation of a crown
7.4.1 For accidental dental benefits what additional documentation is required
For accidental benefits the damage must also be described along with any future treatment required
7.4.1 What is predetermination for dental work and when is it used
predetermination of benefits may be requested by individuals or required by insurers for expensive dental treatment.
Supporting material such as x-rays, study models and operative reports may be requested by the insurer
Usually this is for treatment above a certain dollar amount such as major restorative work, installation of inlays, crowns, bridges or orthodontic treatment
7.4.2 Describe the role of a CDAnet
This system eliminates redundant data entry and verifies all claims information has been entered.
Information compiled is also used for statistical analysis to eliminate rarely used procedure codes and expand codes as new processes are developed
What is CDAnet
The Canadian Dental Association network
Claims adjudication can be performed in real time and the EOB can be sent electronically stating the amount covered or declining the claim
What does EOB stand for
Explanation of benefits
7.5.1 Explain why early intervention is important in disability claims management
Early intervention helps determine the potential for rehabilitation and whether vocational assessment or retraining is necessary
It can help keep STD claims from turning into LTD
7.5.2 Outline the documentation necessary to process a CI insurance claim
- written notification within 1-3 months of diagnosis
- physician’s statement & Diagnosis information
The insured must survive a period of time after diagnosis (usually 30 days)
What does CI stand for
Critical Illness
7.6.1 Explain how benefit payments are determined when an insured individual has duplicate coverage under two or more group plans that both have a COB provision
The first payer pays eligible expenses as though the member had no other benefits
The second payer pays the lesser of 100% of the loss less the amount paid by the first payer and the amount it would have paid if it had been first payer
What happens when an insured has coverage under two plans with the same insurer
When the insured has coverage under two plans with the same insurer that insurer acts as both second and first payer and allocates the costs to the plans accordingly
7.6.3 Identify the first payer when an insured individual with an out of country health provision is covered by more than one group insurance plan
The first payer is the first plan the receives a claim.
The first payer must manage the claim including contacting other insurers.
If the first payer isn’t liable they must advise the individual and provide instructions to contact other plans/insurers. They must also alert other insurers
7.6.4 Outline the information that the first payer must provide to other plans/insurers after an out of country benefit with a COB provision is paid
Documents are forwarded to other insurers who determine what they would have paid had they been first payer.
The first payer determines the level of liability based on
1) Mutually covered expenses to be shared between all units
2) Deductibles that are consistently applied to common item covered that incurs the largest expense
The the other plans/insurers may the first payer and the claimant is informed that the plans will coordinate benefits
7.6.5 Identify the unique considerations addressed by CLHIA COB guidelines regarding out of country benefits coverage for retirees
If a retiree has group coverage with an overall lifetime maximum of $50,000 or less coordination of out of country health care benefits is not required.
This provision is designed to avoid a situation where a retiree may reach the lifetime maximum with an out of country claim
7.6.6 Explain how positive enrollment facilitates COB under a group health care plan
Specific dependent information is usually collected as positive enrollment to safeguard against fraudulent or ineligible claims to facilitate COB
This information is also used to verify eligibility of dependents and facilitate COB.
Claims are checked against COB information. The drug card indicates whether the plan is the first payer
7.7.1 Describe the purpose of the CLHIA guideline G4 coordination of benefits group health and dental
This guideline to help promote consistency in determining the priority in which payments are made and to outline the minimum amount payable by each group plan in situations where a covered individual can submit a claim to more than one group plan.
The combined payment from all plans cannot exceed 100% of the eligible expense.
7.7.2 Describe the scope of the CLHIA guideline G4 coordination of benefits group health and dental
Guideline G4 applies to both insured and noninsured plans that have group health and dental benefits
It does not address out-of-country coordination of benefits.
In the event of conflict with the law the law takes precedence
7.7.3 Indicate which group health care plan will pay first in respect of a claim for an individual who has group coverage under both of his or her part-time employers’ plans
An insured individual who has benefits coverage and the same status under more than one plan first received coverage under the plan that has covered them the longest
7.7.4 Indicate the order of payment when a retiree has health care coverage under the retiree benefit plan of two or more former employers
The plan that has been in effect the longest pays first
7.7.5 Indicate the order of payment for a postsecondary student who also has coverage as a dependent under his or her parent’s plan
The student will first receive payment under the school’s plan and then under the parent’s plan
7.7.6 Indicate the order of payment for a child whose parent has single custody
The health of the parent having custody pays first; the plan of the spouse of the parent with a custody pays second and the plan of the parent who does not have custody pays third
7.7.7 Explain the purpose of the CLHIA Guideline 17 coordination of benefits for out of country/province/territory
There are two components to an out-of-country claim
1) Emergency assistance - the insurer contacted first will initiate case management in the event of an emergency
2) Claim payment - coverage varies from plan to plan and G17 assists in identifying what if any liability exists under a plan to pay for all or a portion of the expenses claimed
G17 describes the role of the first carrier in management and how to coordinate payments for all plans to ensure total payments don’t exceed expenses.
The intent is to provide effective management, minimize claims assessment and provide assistance to the insured
