Total of covered medical expenses of an insured that goes over a specified insurance claim limit. Also referred to as jumbo claim or shock claim .

Financial system that identifies insurance claims above a certain dollar amount and charges them to a pool that is funded by the charges of all groups who share the pool. This system is established to assist in stabilizing premium fluctuations.
***
A system designed to help stabilize premium fluctuations in smaller groups. Large claims (those over a stated amount) are charged to a pool contributed to by many small groups who belong and share in that pool. The small the group of groups, the lower the poling level. Larger groups will have a larger pooling level.

Dependent on each state’s regulations, but generally defined as a group with 100 or more employees eligible for a group insurance plan.

1. Under Medicare Secondary Payer guidelines, this is a group health plan that covers (a) employees of either a single employer or employee organization that employed at least 100 full-time or part-time employees on 50% or more of its regular business days during the previous calendar year or (b) two or more employers or employee organizations, at least one of which employed at least 100 full-time or part-time employees on 50% or more of its regular business days during the previous calendar year. It includes individual policies (including Medigap policies) purchased by or through an employer or former employer of the individual or family member. 2. Employer-sponsored group health plan that gives insurance coverage for 20 or more employees and is primary to Medicare. This number of employees varies depending on each state’s regulations.

Last date of the patient’s monthly discharge of blood and cellular debris from the uterus through the vagina. This date is expressed as eight digits and placed in Block 14 of the CMS-1500 claim form.

Eligible individual who applies for group health insurance after the 31-day open enrollment period.

Inactive residual effect or condition produced after the acute phase of an illness or injury has ended. There is no time limit on when late effects can appear. For example, an individual could suffer an injury and then years later develop arthritis at that site. When listing the diagnostic code, sequence the condition code first and then the late effect code, unless the late effect code is combined with the manifestation in one code or the late effect is followed by the manifestation. Also known as sequelae .

Dollar amount an individual must pay if there is a time limit for enrollment into a health plan and the patient delays enrollment beyond the deadline.

Under a Medicare Part D plan, this phrase means it is the extra dollar amount added to the monthly insurance premium if the Medicare beneficiary does not enroll when first eligible unless he or she is covered by creditable coverage from another plan. The penalty is 1% for every month past the end of the initial enrollment period that was May 15, 2006.