A ______ is an organization that handles the administrative duties of claims administration. They are typically used by organizations that self-fund health benefits but do not find it effective to administer the plan themselves.

___ is the practice of contracting a specific work process or processes to an external service provider. These services can include claims processing, billing, customer service, etc.

_____ is a federal legislation which regulates the majority of private pension and welfare group benefit plans in the United States.

True or False: Group Insurance is any insurance plan under which a number of individuals are covered by a single plan issued to their employer (or other group concern with a common interest other than group coverage). Individual certificates or booklets are given to each employee

A _________ is a fixed amount of health care dollars which an individual must pay before health benefits begin.

A _______ is a defined group of providers, typically linked through contractual arrangements, which supply a full range of primary and acute health care services

A _________ is a fee charged to managed care members to offset costs of paperwork and administration for each office visit or pharmacy prescription filled.

_____________ is an employee benefit plan funded through financial vehicles other than insurance contracts. The employer assumes the risk of paying all claim costs incurred by covered employees.

________ is the percentage of the costs of medical services paid by the patient.

A __________ is a provision written in plans that allows any covered expenses which are applied to the deductible, during the months October - December, to be applied to the deductible for the following year.

________ is the right to continue health benefit coverage after an employee’s membership is terminated or the employee resigns

A _____________health plan is any group health plan or individual coverage that was in effect on 3/23/10, the date of enactment.

An ________ Health Plan is for people with low income and medical needs. It is a Plan similar to Medicaid, but run by a County or Hospital District.

True or False: An Employee or Dependent that enrolls in the plan more than 30 days after eligible is considered a late entrant unless he/she qualifies for a special enrollment period.

The _______________ is the maximum dollar amount a covered person will pay for covered expenses in any benefit period, unless otherwise specified in the Schedule of Benefits. Once the participant meets this, all benefits are considered at a 100% for the remainder of the benefit period, unless otherwise stated in the Benefit schedule.

True or False: a Fully insured plan is when the employer purchases insurance coverage and assumes the full risk of paying all claims

___________ is the process of reviewing the medical necessity of certain services to manage plan costs and ensure that the most appropriate care is rendered for the service

True or False: Our PPO plans do not require a referral to see a specialist