Compliance & Privacy
This federal law requires CSRs to verify caller identity and protect all member health information.
What is HIPPA?
An individual who works for a company/organization in exchange for payment and other benefits.
Who is an employee?
Plan that allows you to have access to any provider (in and out of network), no referrals required but typically has a higher premium and lower deductibles.
What is PPO?
This document contains the full explanation of benefits, exclusions, and requirements.
What is a SPD?
This tab in the GRS stores information on the type of ID card offered to members.
What is Eligibility tab?
This is the term used when you only provide the necessary information to complete your task.
What is minimum necessary?
Family members enrolled by the subscriber on the health plan.
Who are dependents?
This plan typically only has in network options and out of network is non-covered.
What is EPO?
This document lists everything the client offers, including vendors used.
What is GRS (Group Reference Sheet)?
This ID card type is used when only the employee receives an ID card with a dependent indicator.
What is Employee ID Card Type?
Phone #, Name, DOB, SSN, Address, etc.
What is PII - Personally Identifiable Information?
This organization manages claims, eligibility, and customer service on behalf of the employer.
What is a TPA - Third Party Administrator?
This plan allows you to pair it with an HSA/HRA account to assist with the higher deductibles.
What is HDHP?
This identifies a members benefit plan they selected, clients can offer several and they can have different coverage options (deductibles, copay, coinsurance, etc.)
What is a benefit package?
This ID card type lists the subscriber’s name and includes a list of covered dependents.
What is Family ID Card Type?
Medical Records, Prescriptions, Claims, etc.
What is PHI - Protected Health Information?
TPA's partner with these to give access to in-network providers of service.
What are networks?
This plan pairs with a tiered plan and is offered to health care system clients.
What is domestic?
These 3 character codes indicate what benefits the member has enrolled in (medical, dental, pharmacy, etc).
What are riders?
This fixed, flat fee is paid by a patient at the time of service.
What is copay?
This section in the SPD explains the rules around dependent eligibility.
What is Eligibility, Enrollment, Termination?
This is what clients pay TPA's to administer their plan instead of premiums.
What is a PEPM (Per Employee, Per Month) Fee?
The entire family amount must be met before the plan pays benefits for any covered member.
What is non-embedded family deductible?
In the location group code, the 3rd or 4th character will indicate this information...
What is A - Active employee R-Retiree C - COBRA?
How long do we quote the ID card will be received in the mail?
What is 14-30 business days via USPS?