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EDI - Electronic Data Interchange
The transmission of data electronically, typically via a secure FTP (file transfer protocol).

EOB - Explanation of Benefits
A document sent to an insured when a claim is processed by the insurance company or claim administrator. The document explains how reimbursement was made, or why the claim was not paid, and any additional information needed.

Fully Insured Health Benefits
The employer pays a set premium and, in return, transfers all of the risk and responsibility for claims payment to the insurance company. The employer is not at risk for any specific medical costs incurred during the plan year, though the overall medical costs may be used to determine the premiums for the following year.

Health Plan
Refers to a plan of benefits offered through employers, or other entities including, but not limited to, Health & Welfare funds, Labor funds, HMOs and Insurance Companies.

HMO - Health Maintenance Organization
An organization that provides a wide range of health services for a fixed, pre-paid premium. The HMO may provide all services or may contract with other entities for additional services. Often, plan participants are required to seek medical attention first through a or primary care physician, or "gate keeper", who in turn refers them for appropriate specialty medical treatment.

IVR - Interactive Voice Response
The use of verbal instructions via the telephone requiring a response from the listener by pressing a number on the keypad.

Medical Provider
An individual or group of individuals who provide healthcare services, typically physicians and hospitals.

MGU - Managing General Underwriter
Brokers for Reinsurance carriers. Their clients are typically self-funded groups and TPAs (Third-Party Administrators) interested in stop-loss coverage for their health plan.

Network
Contracted providers of healthcare (physicians, hospitals, testing centers, rehabilitation center labs, etc.) that have negotiated discount fees for their services in return for higher patient volume. This can apply to HMO, PPO and POS arrangements.

PHO - Physician Hospital Organization
An organization of healthcare providers, typically associated with a specific hospital, who administer a network, contracting their services at a discount.

POS - Point of Service
A healthcare plan that has a "gatekeeper" physician and a network of providers. Its members are encouraged to use network providers, but can opt to use non-network providers. A POS plan is a hybrid of PPO and HMO type plans.

PPO - Preferred Provider Organization
An organization that contracts with healthcare providers to provide services at discounted fees in exchange for increased patient volume. The terms "PPO" and "network" are used interchangeably throughout this website.

Primary PPO
This is the PPO selected by an organization to provide healthcare services for a health plan in a specific geographic area. Typically, there are financial incentives for using providers participating with the Primary PPO.

PRL - Patient Referral Line
Service provided by CAI that may be offered to plan participants to locate medical providers in their Primary PPO. This feature is accessed by dialing a toll-free number and entering a PIN and ZIP code of your location or area. Directories of participating providers in that area can be faxed automatically to the caller.

ProviderNow
CAI's Internet provider search service. Members can access ProviderNow to search for in-network providers based on several different criteria including provider name, specialty, city, and zip code.

Reinsurance Carrier
This organization accepts part of the financial risk for medical bills on behalf of self insured health plans, HMOs or other entities. They will offer specific and/or aggregate stop-loss coverage to cover losses in excess of specified limits.

RepriceNow
CAI's Internet repricing solution. See Internet Repricing Options on our website.

Self-Funded Plan
An arrangement under which all or a portion of the medical costs are accepted and paid by an employer or other entity providing benefits for covered members including, but not limited, to Health & Welfare funds and Labor funds.

Stop-Loss
A type of high-dollar insurance that a payor buys to "stop" or "cap" the financial loss from unexpectedly high medical claims. "Specific Level" and "Aggregate Level" are components of Stop-Loss.

Supplemental PPO
These are PPOs that by contract authorize CAI to access discounts on out-of-area / out-of-network medical bills without network logos or benefit differentials. These discounts result in lower out-of-pocket costs for the plan participant and greater savings for the employer or health plan.

TPA - Third-Party Administrators
A third-party administrator is an organization that typically provides claim and benefit administration on behalf of self-insured employers. They may be used in lieu of contracting with an insurance company.

Wrap PPO
Similar to Supplemental PPOs, these networks by contract authorize CAI to access discounts on out-of-area / out-of-network medical bills. However, they typically require their network logo be placed on the patient's ID card to utilize the discounts for their providers.