Unit 25 Flashcards
All insurers in CO offering Hospital/Surgical/ Major medical must offer what additional services for purchase
Home and Hospice coverage
How long to pay uncontested claims
30 days if submitted electronically, 45 days otherwise
How to request additional info after receiving claim
30 days
How long to pay/ deny any claim
90 days
How long to make a prospective review decision
15 days
What is Adverse Decision
A decision made to deny/reduce/terminate/fail to provide requested benefit
How long to make urgent care determinations
Asap but no later than 72 hrs
How long to make Extended stay/ additional services determinations
ASAP but not later than 24 hrs
How long to make retrospective review determinations
30 days
Who is eligible for a standard appeal
All covered persons
How many levels is an internal appeal review
2
Who must be accepted for individual health plans in CO
Every eligible applicant
What is the open enrollment period for CO
Nov 1-Dec 15
How long is the special enrollment period after a triggering event
60 days
How long is the grace period for an individual that receives the Advance Payment Tax Credit
3 months
How long does an employer have to notify an employee of their right to continue coverage after termination
10 days
How long can coverage continue after termination
18 months
Person authorized by health providers to negotiate on their behalf
Intermediary
Demographic characteristics that are considered by the carrier in determination of premium rates
Case Characteristics
What level of renewability are Medicare Supplement plans
Guaranteed renewable
What is the minimum benefit period for LTC
12 months
What is the minimum renewability level for LTC
Guaranteed Renewable
The transfer of insured’s right of recovery to the insurance company
Subrogation
What must the producer disclose
They receive commissions
If dispute occurs as to whether injury is coverable by worker’s comp who pays the expenses
Insurance company and should be coverable worker’s comp will reimburse with 12% interest
