module 6 Flashcards
Determining an appropriate administrative approach, performing activities such as enrollment, and evaluating the overall program and specific benefits.
plan administration
Administration functions
performed in-house by
the plan sponsor.
self administration
Administrative functions
performed by the insurer.
insured administration/home office administration
Administrative functions
performed by a TPA
TPA
An arrangement where the plan sponsor pays a fee to the insurer for performing claims validation and adjudication services.
admin services only ASO
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.
claims settlement only
A document customized to a plan sponsor, outlining the plan sponsor’s specific plan provisions and routine and non-routine administration functions.
adminstration manual
Date an employee’s
coverage begins; whether
a waiting period must be
satisfied.
date of eligibility
An individual not enrolled
within 31 days of their
eligibility for coverage.
late enrollment
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.
COB coordination of benefits
The process of collecting more detailed dependent information at the time of enrollment to facilitate coordination of benefits.
positive enrollment
A period of time that must be satisfied before a new applicant is eligible for benefits coverage.
waiting period
The process to determine whether the insurer has a contractual obligation to pay a claim, at what amount, and to whom.
adjudication process
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.
benefits booklet
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.
Id cards/certificates
A document prepared for each premium due date reflecting all transactions processed during the month.
premium statement
A 31-day period after the
premium due date when
the premium can be
received.
premium payment grace period
Type of self-insured billing
statement that reflect all
transactions during the
month.
billed in arrears plan billing statements
A report that includes information on premiums and claims by benefit for a specified reporting period.
experience reports
A report that reconciles paid premiums against claims charges/expenses for the contract period; a statement of the plan’s financial performance.
annual financial report
For non-refund plans, a report that shows only premiums, claims and waiver of premiums/disabled reserves.
abridged financial report
At contract anniversary, insurer setting required premium rates, pool charges, retention charges, or ASO deposit/billed rates for the new policy year.
renewal rating
For plans underwritten on a refund accounting basis, a document that outlines the terms and conditions of the underwriting basis.
financial letter of agreement
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.
performance standards agreement PSA
