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