module 6

Question 1

Determining an
appropriate
administrative approach,
performing activities such
as enrollment, and
evaluating the overall
program and specific
benefits.

Answer 1

plan administration

Question 2

Administration functions
performed in-house by
the plan sponsor.

Answer 2

self administration

Question 3

Administrative functions

performed by the insurer.

Answer 3

insured administration/home office administration

Question 4

Administrative functions

performed by a TPA

Answer 4

TPA

Question 5

An arrangement where
the plan sponsor pays a
fee to the insurer for
performing claims
validation and
adjudication services.

Answer 5

admin services only ASO

Question 6

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.

Answer 6

claims settlement only

Question 7

A document customized to a
plan sponsor, outlining the
plan sponsor’s specific plan
provisions and routine and
non-routine administration
functions.

Answer 7

adminstration manual

Question 8

Date an employee’s
coverage begins; whether
a waiting period must be
satisfied.

Answer 8

date of eligibility

Question 9

An individual not enrolled
within 31 days of their
eligibility for coverage.

Answer 9

late enrollment

Question 10

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.

Answer 10

COB coordination of benefits

Question 11

The process of collecting
more detailed
dependent information
at the time of enrollment
to facilitate coordination
of benefits.

Answer 11

positive enrollment

Question 12

A period of time that
must be satisfied before
a new applicant is
eligible for benefits
coverage.

Answer 12

waiting period

Question 13

The process to determine
whether the insurer has a
contractual obligation to
pay a claim, at what
amount, and to whom.

Answer 13

adjudication process

Question 14

A document that
describes the benefits
provided under a plan
issued to each insured
individual and written in
an easy-to-read or userfriendly
format.

Answer 14

benefits booklet

Question 15

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.

Answer 15

Id cards/certificates

Question 16

A document prepared
for each premium due
date reflecting all
transactions processed
during the month.

Answer 16

premium statement

Question 17

A 31-day period after the
premium due date when
the premium can be
received.

Answer 17

premium payment grace period

Question 18

Type of self-insured billing
statement that reflect all
transactions during the
month.

Answer 18

billed in arrears plan billing statements

Question 19

A report that includes
information on premiums
and claims by benefit for
a specified reporting
period.

Answer 19

experience reports

Question 20

A report that reconciles
paid premiums against
claims charges/expenses for
the contract period; a
statement of the plan’s
financial performance.

Answer 20

annual financial report

Question 21

For non-refund plans, a
report that shows only
premiums, claims and
waiver of
premiums/disabled reserves.

Answer 21

abridged financial report

Question 22

At contract anniversary,
insurer setting required
premium rates, pool
charges, retention charges,
or ASO deposit/billed rates
for the new policy year.

Answer 22

renewal rating

Question 23

For plans underwritten on
a refund accounting
basis, a document that
outlines the terms and
conditions of the
underwriting basis.

Answer 23

financial letter of agreement

Question 24

A document that outlines
best practices on behalf of
one or more parties involved
in plan administration;
usually executed between
the insurer and plan sponsor.

Answer 24

performance standards agreement PSA