Module 7

Question 1

The process of
determining whether a
claim is eligible to be
paid, at what amount,
and to whom.

Answer 1

claims adjudication

Question 2

Settlement of a
claim in full or in
part.

Answer 2

claims payment

Question 3

An employee of an
insurer/TPA that is
responsible for
adjudication/processing
claims.

Answer 3

claims analyst

Question 4

A statement provided
to plan members
describing the
process by which a
claim was
adjudicated.

Answer 4

explination of benefits EOB

Question 5

The usual period for
processing and paying
a group death benefit
claim, from receipt of all
necessary
documentation.

Answer 5

standard turn around time

Question 6

Written proof
that an insured
individual has
died.

Answer 6

proof of loss

Question 7

A type of
beneficiary
requiring a
guardian or
trustee.

Answer 7

minor beneficiary

Question 8

The beneficiary
who receives
benefits if the
original beneficiary
is not alive when a
plan member dies.

Answer 8

primary vs contingent beneficiary

Question 9

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.

Answer 9

facility of payment provision

Question 10

An adjustment to a
disability benefit
amount because
of approved
government
benefits.

Answer 10

CPP QPP benefit offsets

Question 11

Determination of the
order in which
carriers adjudicate a
claim if an
employee is
covered by more
than one plan.

Answer 11

first payer vs second payer

Question 12

Industry guidelines for
allocating financial
liability among insurers
when an insured
individual has coverage
under more than one
plan.

Answer 12

canadian life and health insurance association CLHIA COB guidelines

Question 13

Collection of
specific dependent
information to
facilitate
coordination of
benefits.

Answer 13

positive enrollment

Question 14

A file with each plan
member’s claims, usually
retained for seven years.

Answer 14

claims history

Question 15

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.

Answer 15

COB provision

Question 16

Amounts deducted
from the eligible
amount of expenses
payable, either per
item or per
calendar year.

Answer 16

cal year or per item deductibles

Question 17

The amount that is
reimbursed, if it is
less than 100%

Answer 17

coinsurance

Question 18

Means of
identifying the
dental
treatment
provided.

Answer 18

dental procedure code

Question 19

The reasonable
and customary
rates for dental
procedures.

Answer 19

dental fee guide

Question 20

The electronic
claims information
interchange
between dentists
and insurers.

Answer 20

CDAnet

Question 21

The period during
which a plan
member must be
continuously
disabled before
becoming eligible
for benefits.

Answer 21

elimination period

Question 22

A benefit provided
under the disability
provision of life
insurance benefits
up to 12 months
after ceasing work
due to total
disability.

Answer 22

waver of premium

Question 23

An event where
the insured and
the beneficiary die
at the same time.

Answer 23

common disaster

Question 24

How each claim is
registered so that details
are available for
reporting and in the
event of questions from
the claimant, on claim
status.

Answer 24

CID

Question 25

Steps in the adjudication
system that validate
claims, including
verification of eligibility,
that the expense is
covered, and benefit
calculations.

Answer 25

edits or checks

Question 26

The number that
indicates that a
drug has been
evaluated and
approved for sale.

Answer 26

DIN

Question 27

Adjudication
performed
online.

Answer 27

Electronic adjudication