Module 6 Flashcards
Plan Administration
Determining an appropriate administrative approach, performing activities such as enrollment, and evaluating the overall program and specific benefits.
Self Administration
Administration functions performed in-house by the plan sponsor.
Insurer administration/hoe office administration
Administrative functions performed by the insurer.
Third-party administration
Administrative functions performed by a TPA
Administrative Services Only (ASO)
An arrangement where the plan sponsor pays a fee to the insurer for performing claims validation and adjudication services.
Adjudication process
The process to determine whether the insurer has a contractual obligation to pay a claim, at what amount and to whom.
Benefit booklet
A document that describes the benefits provided under a plan issued to each insured individual and written in an easy-to-read or user-friendly format.
ID Cards/Certificates
Documents issued to each plan member as evidence that he or she is covered including such information as the plan member’s name and ID number.
Premium Statement
A document prepared for each premium due date reflecting all transactions processed during the month.
Premium payment grace period
a 31-day period after the premium due date when the premium can be received.
Claims Settlement Only
A type of TPA arrangement where the TPA is responsible for all aspects of some or all claims but not maintaining eligibility, billing or reporting.
Administration Manual
A document customized to a plan sponsor, outlining the plan sponser’s specific plan provisions and routine and non-routine administration functions.
Date of Eligibility
Date an employee’s coverage begins; whether a waiting period must be satisfied.
Late enrollment
An individual not enrolled within 31 days of their eligibility for coverage.
Coordination of Benefits (COB)
When an individual is covered under two or more group plans and can claim to a combined maximum of 100% of the cost of the eligible expense.
