Module 7 Flashcards
The process of determining whether a claim is eligible to be paid, at what amount, and to whom.
claims adjudication
Settlement of a
claim in full or in
part.
claims payment
An employee of an insurer/TPA that is responsible for adjudication/processing claims.
claims analyst
A statement provided to plan members describing the process by which a claim was adjudicated.
explination of benefits EOB
The usual period for processing and paying a group death benefit claim, from receipt of all necessary documentation.
standard turn around time
Written proof
that an insured
individual has
died.
proof of loss
A type of beneficiary requiring a guardian or trustee.
minor beneficiary
The beneficiary who receives benefits if the original beneficiary is not alive when a plan member dies.
primary vs contingent beneficiary
A provision that allows a portion of a death benefit to be paid to an individual other than the beneficiary who has paid the plan member’s expenses associated with illness and a funeral prior to death.
facility of payment provision
An adjustment to a disability benefit amount because of approved government benefits.
CPP QPP benefit offsets
Determination of the order in which carriers adjudicate a claim if an employee is covered by more than one plan.
first payer vs second payer
Industry guidelines for allocating financial liability among insurers when an insured individual has coverage under more than one plan.
canadian life and health insurance association CLHIA COB guidelines
Collection of specific dependent information to facilitate coordination of benefits.
positive enrollment
A file with each plan
member’s claims, usually
retained for seven years.
claims history
A provision allowing an individual covered under two or more group plans to claim to a combined maximum of 100% of the cost of the eligible expense.
COB provision
Amounts deducted from the eligible amount of expenses payable, either per item or per calendar year.
cal year or per item deductibles
The amount that is
reimbursed, if it is
less than 100%
coinsurance
Means of identifying the dental treatment provided.
dental procedure code
The reasonable
and customary
rates for dental
procedures.
dental fee guide
The electronic claims information interchange between dentists and insurers.
CDAnet
The period during which a plan member must be continuously disabled before becoming eligible for benefits.
elimination period
A benefit provided under the disability provision of life insurance benefits up to 12 months after ceasing work due to total disability.
waver of premium
An event where
the insured and
the beneficiary die
at the same time.
common disaster
How each claim is registered so that details are available for reporting and in the event of questions from the claimant, on claim status.
CID
Steps in the adjudication system that validate claims, including verification of eligibility, that the expense is covered, and benefit calculations.
edits or checks
The number that indicates that a drug has been evaluated and approved for sale.
DIN
Adjudication
performed
online.
Electronic adjudication
