Employer Sponsored Health Plans
This is the part of the team that is hired to handle the pharmacy benefits and pay pharmacy claims
Pharmacy Benefits Manager
This part of the team is responsible for maintaining and communicating the groups' eligibility file
TPA
General Practice, Internal Medicine, Family Medicine and Pediatricians are examples of
Primary Care Physicians
This is the complete outline of the plan and is also known as the "constitution" of the plan
SPD (Summary Plan Description)
The tool that PSRs use to quote benefits
SBS
Most of the plans that Quantum Health provides customer service and medical management are this type of plan
Employer Sponsored/Self-Insured
When providers are calling in for Eligibility, the PSR should quote this
Effective date
An additional network that the plan contracts with for members who are temporarily outside of the primary network area
Wrap network
The percentage of shared costs paid by both the member and the health plan, usually once the deductible has been met
Coinsurance
A fixed dollar amount the member must pay before the plan starts to pay a certain percentage
The TPA is hired to perform what two functions for the self-insured health plans
Administer the plan and pay medical claims
A critical piece of information that tells us who is covered, under which plan and for how long
Eligibility
This is a common network style for hospital systems
Tiered Network
An employer funded account that is meant to help offset the costs of a high deductible
HRA
A dollar or visit limit on a specific benefit
Plan Limitation
This is the individual the employer hires to help build the team of experts for their self-insured plan
Broker/Benefit Consultant
Approximately it takes how long for eligibility information to get to Quantum Health
2 weeks or 14 days
This type of specialist sees patient with diabetes
Endocrinologist
Employers may have a referral incentive for specialist office visits to encourage the member to do what
Start their care with a PCP
A fixed dollar amount a member must meet during the plan year before the plan starts to pay 100% for covered services done INN
OOP Max
Why would an employer chose to become self-insured
Name the order in which eligibility information is updated
Employee to Employer to TPA to Quantum Health
The PSR should quote from this section of SBS for sick office visits with an OBGYN
PCP Office Visit
If a member is diagnosed with an acute or chronic condition like cancer, the PSR should do what
What two ways do health plans calculate the allowed amount for out-of-network providers
Medicare Allowable and Usual & Customary