Plan Design
This is a set amount the member must pay before the plan begins to pay for certain services
Deductible
This is the first hire for the employer, in order to help build the SPD and the TEAM of experts that supports Employer Sponsored Plans
Broker or Benefit Consultant
A group of providers that offers their services at a lower than usual rate or discount rate
Network
What are the four types of Primary Care Providers?
Family Medicine, General Practice, Internal Medicine and Pediatrician
If a member is diagnosed with an acute or chronic condition like COPD, the PSR should do what
Send a PCG referral
The rules of the health plan are outlined in this document
Summary Plan Description or SPD
This member of the TEAM is responsible for paying pharmacy claims and administering the pharmacy benefits
Pharmacy Benefits Manager or PBM
When calling the network to verify network status, you need these pieces of information
Double Jeopardy!
This type of specialist can see a patient with diabetes
Endocrinologist
The percentage of shared costs shared by the member and the health plan, usually once the deductible has been met
Coinsurance
Approximately it takes how long for eligibility information to get to Quantum Health
2 weeks or 14 days
Tiered Network
If this type of provider calls in for benefits you should always check SBS to confirm if there is a referral incentive on the plan
Specialist
Double Jeopardy!
This spending account can be funded by both the employer and the employee, it rolls over year to year AND employer to employer
HSA or Health Savings Account
Claims processing and overall administration of the health plan is done by this member of the TEAM
TPA or Third Party Administrator
Wrap/Travel Network
The section of SBS you should quote benefits for a non-routine visit with an OBGYN
PCP Office Visit Section
Employers may have a referral incentive to encourage their member's to do this
Start their care with a PCP
These are the reasons why employers decide to become employer sponsored/self-funded
Control plan design and Save money
Double Jeopardy!
The plan may implement this exception in an emergency situation where the member cannot control which provider cares for them
OON Pay As INN or OONPAI
If a member is diagnosed with cancer, they may see this type of provider
Oncologist