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Glossary
Add-on
An enrollee (subscriber) added to an existing employer group.
Adjudication
Processing claims according to contract.
Allowable Charge
The maximum charge for which a third party will reimburse a provider for a given service. An allowable charge is not necessarily the same as either a reasonable, customary, maximum, actual, or prevailing charge.
Allowed Amount
Maximum dollar amount assigned for a procedure based on various pricing mechanisms. Also known as a maximum allowable.
Anniversary Date
The beginning of an employer group's benefit year. The first day of effective coverage as contained in the policy Group Application and subsequent annual anniversaries of that date. An insured has the option to transfer from an indemnity plan (which may have maximum benefit levels) to an HMO.
Approval
A term used extensively in managed care and, too many, implies the primary process of "managing" managed care. Approval usually is used to describe treatments or procedures that have been certified by utilization review. Can also refer to the status of certain hospitals or doctors, as members of a plan. Can describe benefits or services which will be covered under a plan. Generally, approval is either granted by the managed care organization (MCO), third party administrator (TPA) or by the primary care physician (PCP), depending on the circumstances.
Approval Date
The date an employer group is approved with all paperwork processed and accepted. Case is considered covered by ChoiceBuilder® at this point. It is possible for a case to be approved for a retroactively coverage. The condition which exists when the person or object to be insured meets the underwriting standards of the insurer.
Balance Billing
The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.
Beneficiary (Also eligible; enrollee; member)
Individual who is either using or eligible to use insurance benefits, under an insurance contract. Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. An individual who receives benefits from or is covered by an insurance policy or other health care financing program.
Benefit Limitations
Any provision, other than an exclusion, which restricts coverage in the Evidence of Coverage, regardless of necessity.
Benefit Package
Aggregate services specifically defined by an insurance policy or HMO that can be provided to patients. The services a payer offers to a group or individual.
Benefit Payment Schedule
List of amounts an insurance plan will pay for covered health care services.
Benefits
Benefits are specific areas of Plan coverage's, i.e., outpatient visits, hospitalization and so forth, that makes up the range of medical services that a payer markets to its subscribers. Also, a contractual agreement, specified in an Evidence of Coverage, determining covered services provided by insurers to members.
Broker
One who represents an insured in solicitation, negotiation, or procurement of contracts of insurance, and who may render services incidental to those functions. By law, the broker may also be an agent of the insurer for certain purposes such as delivery of the policy or collection of the premium.
Cal-COBRA (California Continuation Benefits Replacement Act)
California law requiring employers with 2-19 employees to offer continued health care coverage (medical, dental, and vision) to employees and their dependents who lose coverage through qualifying events similar to Federal COBRA.
Calendar Year Deductible
A deductible that applies to any eligible expenses incurred by the insured during any one calendar year.
Capitated Plan
An HMO's provider-contracting model whereby a physician is paid a flat fee per year, per subscriber who uses that particular doctor. The physician in return must treat that subscriber as often as needed. Providers are not reimbursed for services that exceed the allotted amount. The flat fee may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilization.
Capitation
A reimbursement system for providers of primary care services who receive a pre-payment for every member assigned to that provider for that month.
Carrier
An insurer; an underwriter of risk that finances health care. Also refers to any organization which underwrites or administers life, health or other insurance programs.
Carryover Deductible
The deductible payable includes the portion of the deductible satisfied before the continuation coverage became effective.
Case
A quote is considered a case when enrollment application is received at ChoiceBuilder Underwriting department. A case evolves through a life cycle of the following stages: Received, Pending, Rolled, Approved, Declined. Also may be known as a sold case.
Certificate of Coverage (COC)
Outlines the terms of coverage and benefits available in a carrier's plan.
Claims Review
The method by which an enrollee's service claims are reviewed prior to reimbursement. The purpose is to validate the necessity of the provided services and to be sure the cost of the service is not excessive.
COBRA (Consolidated Omnibus Budget Reconciliation Act)COBRA requires continuation coverage to be offered to covered employees, their spouses, their former spouses, and their dependent children when group coverage would otherwise be lost due to certain specific events. Those events include the death of a covered employee, termination, or reduction in the hours of a covered employee’s employment for reasons other than gross misconduct, divorce or legal separation from a covered employee, a covered employee’s becoming entitled to Medicare, and a child’s loss of dependent status (and therefore coverage) under the plan. COBRA generally applies to all group plans maintained by private-sector employers (with at least 20 employees) or by state and local governments. The law does not apply, however, to plans sponsored by the federal government or by churches and certain church-related organizations. COBRA requires that continuation coverage be made available for a limited period of time of 18 or 36 months. The length of time for which continuation coverage must be made available (the “maximum period” of continuation coverage) depends on the type of qualifying event that gave rise to the COBRA rights. A plan, however, may provide longer periods of coverage beyond the maximum period required by law.
Coinsurance
The arrangement by which both the insured and the insurer share, in a specific ratio, the covered losses under a policy. (i.e. An insurer pays 80%, while patient pays 20%).
Commission
The amount of money earned or paid to an insurance agent(s) or broker(s) for selling an insurance policy. A commission is calculated as a percentage of the premium paid by the employer group(s).
Company Name
Employer Group who is currently, historically or potentially covered by ChoiceBuilder.
Contingent Beneficiary
The party designated to receive life insurance policy proceeds if the primary beneficiary should die before the person whose life is insured. Also called the secondary beneficiary or the successor beneficiary.
Contributory Program
Program where the cost of group coverage is shared by the employee and the employer or a union.
Conversion Privilege
The right of an individual insured under a group policy to certain kinds of individual coverage, without an examination, upon termination of his association with the group.
Conversion Provision or Policy
A provision in most policies which allows an individual to convert their group policy to an individual policy, without evidence of insurability, if they are terminated for reasons other than their own request.
Coordination of Benefits (COB)
Provision regulating payments to eliminate duplicate coverage when a claimant is covered by multiple group plans. The procedures set forth in a Subscription Agreement to determine which coverage is primary for payment of benefits to Members with duplicate coverage. Used by insurers to avoid duplicate payment for losses insured under more than one insurance policy. A coordination of benefits, or non duplication, clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered. Standard rules determine which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.
Co-Pay/Co-Payment
A designated dollar amount that an insured must pay to a contracted provider or hospital for eligible service rendered instead of submitting claims or paying a co-insurance percentage. It usually applies to HMO or PPO plans.
Cost Sharing
Payment method where a person is required to pay some costs in order to receive care. The general set of financing arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of services, or both. Cost sharing can also occur when an insured pays a portion of the monthly premium for insurance.
Covered Benefit/Service
A necessary service that is specifically provided for under the provisions of an Evidence of Coverage. A covered benefit must always be necessary, but not every necessary service is a covered benefit. For example, some elements of custodial or maintenance care, which are excluded from coverage, may be necessary, but are not covered.
Decline
Employer Group does not meet criteria(s) to receive an approval for coverage by ChoiceBuilder.
Deductible
A flat amount the insured must pay before the insurance company will make any benefit payments under a policy.
Deductible carry over credit
Charge incurred during the last three months of a year that may be applied to the deductible and which may be carried over into the next year.
Defined Contribution Coverage
A payment process for procurement of benefit plans whereby employers contribute a percentage or specific dollar amount toward the costs of insurance coverage for their employees. Sometimes this includes an undefined expectation of guarantee of the specific benefits to be covered.
Dependent
Person covered by someone else's plan. In a payer's policy of insurance, a person other than the subscriber eligible to receive care because of a subscriber's contract.
Deposit & Employee Contribution Statement
The invoice for the first month of coverage premium reflecting deposits made and balance due.
DHMO (Dental Health Maintenance Organization)
An institution that offers prepaid dental care to subscribing members. For a set fee, participants receive all their dental care from the DHMO's own facilities and doctors, or from independents contracted by the DHMO. No benefits are provided of the insured goes out of the network.
Effective date
The date a policy's coverage of a risk goes into effective for employer group and its members. Effective dates are always the first of the month.
Eligible dependent
Person entitled to receive health benefits from someone else's plan.
Eligible employee
Employee who qualifies to receive benefits.
Eligible expenses
Charges covered under a plan.
Eligible person
Person who meets the qualifications of a plan contract.
Employee Contribution
The amount of the premium that a group member pays in a contributory group insurance plan.
Enrolled Group
Persons with the same employer or with membership in an organization in common, who are enrolled collectively in a group plan. Often, there are stipulations regarding the minimum size of the group and the minimum percentage of the group that must enroll before the coverage is available.
Enrollee
Any person eligible as either a subscriber or a dependent for service in accordance with a contract.
Enrollment
Initial process whereby new individuals apply and are accepted as members of a prepayment plan.
Enrollment Date
Date coverage is effective for employer group with ChoiceBuilder.
Enrollment Quote
Quote type that provides employee specific worksheets and information for enrollment in ChoiceBuilder.
EPO (Exclusive Provider Organization)
An insured dental plan that is very similar to an HMO. An EPO provides benefits or levels of benefits only if care is rendered by an institution and/or professional providers within a specified network.
Evidence or Explanation of Coverage (EOC) or Explanation of Benefits (EOB)
A booklet provided by the carrier to the insured summarizing benefits under an insurance plan.
Excess Risk
Either specific or aggregate stop loss coverage.
Exclusions
Conditions or situations not considered covered under contract or plan. Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks.
Extension of Benefits
Insurance policy provision that allows coverage to continue past termination of employment.
Fee Schedule
A list of maximum benefits that will be paid under a group dental contract for certain listed procedures.
Fee-For-Service
Traditional method of payment for services where specific payment is made for specific services rendered.
Flexible Spending Account (FSA)
A plan that provides employees a choice between taxable cash and non-taxable benefits for unreimbursed health care expenses or dependent care expenses. This plan qualifies under Section 125 of the IRS Code.
Funding Method
System for an employer to pay for a health benefit plan. Most common methods are prospective and / or retrospective premium payment, shared risk arrangement, self-funded, or refunding products.
Gatekeeper
A primary care dentist or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. A PCD is involved in overseeing and coordinating all aspects of a patient's dental care.
Grievance Procedures
The process by which an insured can air complaints and seek remedies.
Group Insurance
Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity.
Indemnity
A benefit paid by an insurer for a loss insured under a policy.
Indemnity Carrier
Usually an insurance company or insurance group that provides marketing, management, claims payment and review, and agrees to assume risk for its subscribers at some pre-determined rate.
Indemnity Plan
A traditional insurance policy in which payment is made for services after they are performed. The insured has freedom to choose any dentist.
Individual Plans
A type of insurance plan for individuals and their dependents who are not eligible for coverage through an employer group coverage.
Initial Quote
Quote type that is directed towards the employer and requires the employer only provides basic employee information.
Lapse
Termination of a policy upon the policyholder's failure to pay the premium within the time required.
Last Invoiced Premium
Last generated month's premium.
Late Pay
Payment status for a group who is not current with their premium payments.
Lifetime Maximum
The maximum lifetime benefit which will be paid by the insurance company per person.
Limitation
Conditions for which payable benefits are limited. Detailed information about limitations is usually found in the certificate of insurance.
Line(s) of CoverageBenefits offered by ChoiceBuilder:
- Dental
- Vision (optional)
- Life (optional)
- Chiropractic/Acupuncture (optional)
- Section 125 (optional)
Member Liability
The dollar amount which an insured is legally obligated to pay for services rendered by a provider.
Negotiated Fee Schedule
A schedule of fees, pre-determined and established by the carrier with each contracted provider individually, for services rendered by the provider. The insured will receive these fees as payment up to their coinsurance amount for claims submitted.
Network
An affiliation of providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services. A list of dentists and other providers who provide services to the beneficiaries of a specific managed care organization.
Non-participating Provider
A provider that does not sign a contract to participate in a plan, usually which requires reduced rates from the provider. In commercial plans, non-participating providers are also called out of network providers or out of plan providers. If a beneficiary receives service from an out of network provider, the plan will pay for the service at a reduced rate or will not pay at all.
Out-of-Network Benefits
With most DHMOs, a patient cannot have any services reimbursed if provided by a provider who is not in the network. With PPOs and other managed care organizations, there may exist a provision for reimbursement of out of network providers. Usually this will involve a higher copay or a lower reimbursement.
Out-of-Network Provider
A provider with whom a managed care organization does not have a contract to provide services. Because the beneficiary must pay either all of the costs of care from an out-of-network provider or their cost-sharing requirements are greatly increased, depending on the particular plan a beneficiary is in.
Out-of-Pocket Expenses, Out-of-Pocket Costs
Portion of dental services or costs that must be paid for by the plan member, including deductibles, co-payments and co-insurance.
Participating Provider
Any provider licensed in the state of provision and contracted with an insurer. Usually this refers to providers who are a part of a network. That network would be a panel of participating providers. Each payer assembles their own provider panels.
Pending Item
An incomplete item that requires follow-up from a group before it can be considered for approval by ChoiceBuilder.
PPO (Preferred Provider Organization)
Similar to an indemnity plan, but with a network of providers, the insured is allowed to choose a dentist from a preferred provider list, who has agreed to group pricing and will follow the procedures and policies of the plan, or any other non-network provider. Lower fees are arranged with the network of providers, giving a financial incentive to stay within the network. A higher cost or co-pay is generally required for services obtained from outside sources.
Premium Month
The coverage month for which the premium is invoiced.
Preventive Care
Care that emphasizes prevention, early detection and early treatment, presumably reducing the costs of care in the long run.
Primary Care
Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians -- who are often referred to as primary care practitioners or PCPs.
Primary Care Provider (PCP)
In a managed care organization, a primary care provider is accountable for the total services of enrollees including referrals, and procedures.
Prior Authorization
A formal process requiring a provider obtain approval to provide particular services or procedures before they are done. This is usually required for nonemergency services that are expensive or likely to be abused or overused. A managed care organization will identify those services and procedures that require prior authorization.
Provider
Usually refers to a doctor who provides care. A plan, managed care company or insurance carrier is not a provider. Those entities are called payers. The lines are blurred sometimes, however, when providers create or manage plans, at that point, a provider is also a payer. A payer can be provider if the payer owns or manages providers.
Quarterly Wage and Withholding Report (QWWR)
A quarterly report that must be filed by all businesses with the state. Most carriers require this report to verify eligibility for coverage.
Quote No.
ChoiceBuilder assigns a number to each quote requested.
Receive Date
Date received by ChoiceBuilder.
Referral
The process of sending a patient from one provider to another for services. Plans may require that designated primary care providers authorize a referral for coverage of specialty services.
Renewal
Continuance of coverage for a new policy term.
Renewal Date
The anniversary of the group's enrollment date, when employees are allowed to make coverage changes.
Renewal Period
A period of time when eligible subscribers may elect to enroll in, or transfer between, available programs that are providing coverage. Under a renewal requirement, a plan must accept all who apply during a specific period each year.
Requested Effective Date
The date an employer group has requested a quote for coverage with ChoiceBuilder. It is not necessarily the coverage effective date since quotes may be declined or effective dates may be rolled.
Section 125 ("Premium Only Plan")
A federal law which enables the employee to have fringe benefits, such as child care, medical, dental and vision cost reimbursements, or any part of employee-borne premiums, deducted from his paycheck with pre-tax dollars.
SIC code
Developed by the United States government in to classify businesses according to their primary type of activity. ChoiceBuilder life insurance rates are determined by the employer group's SIC.
Subscriber
Person responsible for payment of premiums, or person whose employment is the basis for membership in a plan.
Termination Date
Date that a group contract expires or an individual is no longer eligible for benefits. Termination date is always the last day of the calendar month.
TPA (Third Party Administrator)
The individual or firm responsible for the administration of a group insurance plan. This may include accounting, sales, underwriting, certificate of issue and claims settlement without financial responsibility for the risk.
UCR (Usual, Customary & Reasonable)
Charges that do not exceed the amount customarily charged for the service by other providers in the area or are otherwise reasonable.
Underwriting
Process of selecting, classifying, analyzing and assuming risk according to insurability. The insurance function bearing the risk of adverse price fluctuations during a particular period. Analysis of a group that is done to determine rates or to determine whether the group should be offered coverage at all.
Waiting Period
A period of time which must elapse before a new employee is eligible to enroll in the company's group insurance plan.
Worker's Compensation
Government-mandated insurance that provides benefits to employees and their dependents if the employees suffer job-related injury, disease or death.
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