Legal agreement between a policy holder and an insurer to outline the terms and conditions for certain services rendered to covered parties
An individual who has received, is receiving or intends to receive health care services.
(Health care services as defined by federal and state regulations.)
Not defined by NAIC
Types of Insurance
Focus on Healthcare
The individual or organization which has arranged? with the insurer to provide insurance for health services for a defined group or a named list of beneficiaries.
4/20/2020: Chat comment.
from David Riddle to everyone:
Example where it does not work - someone buys coverage for their grandkids but the parent (custodial) is called the policy holder (even if not the person who pays for it)
|Sponsor||Organization that arranges/signs off contract with insurance company to provide one or more benefit packages to their employees/sponsored individuals||For Tricare, please see subscriber|
|Insured||Member, Beneficiary||The party(ies) covered by an insurance policy.||Gail/Laurie|
An individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company.
An individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber.
Any individual covered by the benefits offered by an entity, such as an employer or insurance company.
Any individual that selects or is covered by benefits provided by government programs
When policy in force
|Payer, Insurance Company, Third-party Administrator, Repricer|
Public or private party which offers and/or administers health insurance plan(s) or coverage and/or pays claims directly or indirectly. Examples include:
BIN ANSI Issuer Identification Number (IIN)
RxBin - Stands for bank identification number, though it doesn't involve banks and is used to accurately route claims to pharmacy benefit managers (PBM).
The pharmacy industry uses RxBin (required), RxPCN (situational) and RxGrp (situational) to identify pharmacy benefit plans.
RxBIN and RxPCN is analogous to the U.S. zip code + 4. RxBIN (or BIN number), is like the 5-digit zip code that determines the routing destination, and RxPCN (or processor control number), is like the +4, providing a more specific destination.
NCPDP Processor ID Number (BIN) is a six-digit number that health plans use to process electronic pharmacy claims if the health plan doesn't use pharmacy benefit cards with a magnetic stripe. Plans that use cards with a magnetic stripe should use the recommended American National Standards Institute (ANSI) Issue Identifier Number (IIN) for processing electronic pharmacy claims. ANSI issues IIN numbers. NCPDP issues the Processor ID Number (BIN).
Prescription drug routing information, known as 4Rx data, are the four data elements used to process a pharmacy claims.
In Medicare Part D, these four elements uniquely identify the Medicare Part D Sponsor for the beneficiary and are identified by the sponsor during beneficiary enrollment.
The set of four elements are exchanged with CMS contracted entities during eligibility verification, claims processing, and information reporting transactions, as well as post adjudication claim reporting functions.
The 4Rx data are: RxBIN, RxPCN, RXGRP & RxID. 4Rx data allows payment on behalf of the beneficiary to be counted toward TrOOP. (True Out-of-Pocket costs paid by a beneficiary or others on the beneficiary’s behalf that accumulate towards the annual out-of-pocket threshold)
NCPDP Guidance Documents: https://ncpdp.org/Resources/Guidance-Documents.aspx
NCPDP Pharmacy Card Fact Sheet: https://ncpdp.org/NCPDP/media/pdf/NCPDPpharmacyIdCardFactSheet.pdf
Mapping NCPDP Pharmacy Card to X12N 270/271 (eligibility): https://ncpdp.org/NCPDP/media/pdf/Rx_id_card_map_to_270-271.xlsx
NCPDP Medicare Part D Resources: https://ncpdp.org/Resources/Medicare-Part-D
|Processor Control Number|
RxPCN - the Processor Control Number is a secondary identifier used in routing of pharmacy transactions (as noted above, and analogous to the +4 of a nine digit Zip Code +4.
A PBM/processor/plan may choose to differentiate different plans/benefit packages by assigning unique PCNs to them.
PCN is alphanumeric and assigned by PBM/processors making this identifier unique only to their business and there is no registry of PCNs.
The PCN appears on the pharmacy ID card with the BIN/IIN in accordance with rules defined in the NCPDP Pharmacy ID and Combination Card Implementation Guide. This document is available with NCPDP membership. General information is available on the Guidance Documents page under the "Pharmacy and Healthcare Identification Cards" banner.
Not all entities use the PCN to differentiate plans. Some entities may use the Group ID; still others may not need this level of differentiation.
For members who have Medicare part D, this is the patient's member number in the PBM’s system that processes claims
Each PBM has many groups. Rxgroup identifies the group in which the member is enrolled so claims can be process efficiently and correctly. This is not the Employer Group ID for medical claims.
|280.3 For the purposes of the Federal Program Inventory, what is a program?|
GAO defined program in the Glossary of Terms Used in the Budget Process as an organized set of activities directed toward a common purpose or goal that an agency undertakes or proposes to carry out its responsibilities. Within this broad definition, agencies and their stakeholders use the term “program” in different ways. Agencies have widely varying missions and achieve these missions through different programmatic approaches, so differences in the use of he term “program” are legitimate and meaningful.
For this reason, this guidance does not prescribe a superseding definition of “program”; rather, consistent with the GPRA Modernization Act, agencies may identify programs consistent with the manner in which the agency uses programs to interact with key stakeholders and to execute its mission.
OMB Circular No. A–11 (2015)
The order of application of the insurance to health care claims relative to the other insurance policies (Coverages) which an individual may have. This order would generally follow the order convention for Coordination of Benefit and would include consideration of both health care and accident based insurance.
? Account Coverage.priority
-GP Office Visit Copay
-Specialist Office Visit Copay
-Inpatient Hospital Copay
-Urgent Care Copay
-Maximum Out of Pocket