Glossary

Objectives

After completing this lesson, you will be able to:

  • General Terms

Glossary

TermDefinition
Active Quarterly PremiumA premium that includes all group health and dental premiums (fully insured and ASO fees included). There are some product exclusions from total premium that is currently limited to Life and Voluntary products, but this can change subject to management direction.
Administrative Services Only (ASO)Self insured; Group business for a health plan for which the plan usually provides a network of contracted providers, processes enrollment, claims and other administrative services and in return receives an administrative fee from the group. The Group funds all claims payments and therefore accepts the risk associated with the coverage. These groups differ from fully funded groups by the fact that the group does not pay Premium but rather is invoiced only for the admin fees, claims amounts, reinsurance coverage and other miscellaneous items.
AgencyA firm that hires one or more agents to buy or sell products. In most cases, the agents sell the business, the carrier pays the agency, and the agency then pays the agents. An agent can work for an agency for some types of business and work as an individual for other types of business.
Age RelatedA commission structure that uses the policy holder’s age to locate the commission rate.
Application Received DateThe date that the client receives a customer application. For Medicare business, a lot of processing logic is based on the date which the customer signed the application or the date on which the client received the application, not the Enrollment Effective Date. For example, the requirement for the broker to have an active License may be based on the application received date rather than the individual’s Enrollment Effective Date; application Signed Date.
Appointment PeriodTime range for which the appointment is valid.
Annual Election Period (AEP)Represents the timeframe during which individuals can submit applications for enrollment for the upcoming year.
AppointmentsAccreditation awarded to agents/brokers by the state or Department of Insurance. Brokers may need to obtain an appointment for each product that they sell.
Attestation DateThe date the broker confirms ("attests") that he/she has completed the required training and is eligible to sell certain products for the upcoming or current enrollment season. The client may require the broker/agent to attest to training for a type of business (such as Medicare, Commercial, etc.) or for specific products (such as HMO, PPO, etc.).
AuditsTracks all changes to a record or specific entity within the application; all historical changes are stored in the Audit table.
Automated Clearing House (ACH)A system of the U.S. Federal Reserve Bank that provides Electronic Funds Transfer (EFT) between banks.
Billing PeriodProcessing period; defines the current processing period within the system.
BonusA method for generating additional compensation based on achieving predefined performance goals. Bonuses are typically paid quarterly or annually.
BrokerThe sales representative who sells the policy or product. Also known as agent, producer, or sales representative. The broker may be an individual or firm that charges a fee or earns commission for executing the buy and sell of orders submitted by an investor. A broker may also be one who represents an insured in solicitation, negotiation, or procurement of contracts of insurance, and who may render services incidental to those functions.
BrokerCustomerData entity within the database which describes/connects the relationship between a broker and a customer.
BrokerDetailData entity within the database which describes/connects all details associated to a broker record.
Brokered GroupsA term used to indicate that the group (customer) has an external broker as the writing agent.
CarrierAn insurance company that provides products and/or services in a specified geographical area.
ChargebacksA method of recovering commissions that were previously paid. Chargebacks may be generated when configuration changes result in a lower commission amount being computed or when the client’s enrollment changes resulting in a lower commission amount. These changes may result in a full chargeback of all commissions for the sale or a partial chargeback.
ClientA company using products and/or services provided by SAP/APMe.
CMSCenters for Medicare and Medicaid Services (CMS). A US Government Agency that administers Medicare, approves/rejects Medicare applicants and pays portion of Medicare Premiums.
CodesValues and descriptions stored within the Codes table are displayed as drop down selections throughout the APMe application.
Commercial PlansThe traditional employer group or individual healthcare coverage that can be purchased directly from the insurer or through an insurance agent.
CommissionCompensation paid for selling products. May include a standard commission rate, a special broker fee, or a performance bonus.
Commissionable PremiumPremiums excluded from the commission payment processing.
Commission CapsImposed limits or "caps" on the total commission payments to producers for specific policies or groups.
Compensation AgreementA legal agreement between the client and the broker, which specifies the relationship between the parties involved, commission rates, performance covenants, schedule of benefits, and other pertinent conditions; compensation method
Configuration related dataData used to configure the commissioning system to meet the needs of the user (broker, payee, customer, schedule data)
CustomerEntity purchasing the product or service.
Data DictionaryCatalog of terms and definitions found within APMe.
Date bandedDate range; defines a start date and end date for data.
Department of InsuranceEach state has a Department of Insurance branch that is responsible for supervising and regulating the insurance business; may include awarding accreditation to brokers/agents.
DifferentialsA method of reduce an upline producer’s commissions based on the commissions paid to the downline producers. Refer to the "Hierarchy Structure" for more details.
Downline ProducerA broker who may trigger commissions for one or more upline producers based on his/her relationship with the upline producers.
DrawFixed or minimum payment amounts to brokers.
Earned Health PremiumPremium amount supplied by Underwriting on the group that is applicable towards commissionable premiums. This will be on the transactions for the group.
Effective DateDate which any changes that need to be made to a commissions processing environment become effective.
EntityAny piece of data or a table within the database.
Entity EditsProvides the ability for the client to create Warning Messages or Error Messages to enforce their configuration rules.
Entity Summary ViewsUsers can add summarized views of entity data that can then be used in the entity’s related search forms, detail forms, and entity context menus.
Error and Omissions Insurance (E&O)Brokers may be required to maintain Errors & Omissions Insurance (Professional Liability Insurance) in order to sell products. Clients may also require that the brokers maintain a certain E & O coverage amount.
Expiration DateDate which any changes that need to be made to a commissions processing environment end or become expired.
ExpressionA method to add logic (i.e. simple programming statements) to derive a value. Expressions are used throughout APMe (e.g. Field Defaults, Entity Edits, Transaction Defaults, Formulas).
External BrokerA broker, producer, agent, etc. that is not employed by the company who is calculating/paying the commissions, but instead has a contract to sell the company’s products. These individuals are not paid a salary by the company and the commissions are the basis of their income. Other titles for External Broker include External Rep and External Sales Rep.
Fee ExpressionProvides the ability for a Formula to compute a fee compensation amount (AmtFee) in addition to the base commission (AmtComm).
Fee for ServiceA term used to indicate that the broker is paid a specific amount for the service provided.
Field DefaultsMaintains the user-defined default value for a specific entity field; these defaults override any system-defined defaults pre-packaged in the system. Only users with administrative privileges are allowed to define field defaults.
File SweepMany files need to be Imported and Posted at once. File Sweeps are useful for both of these tasks. A File Sweep scans an FTP server for files matching a specified pattern, then processes the resulting file(s), if any match the criteria. After processing the files, the File Sweep may remove the file, archive it, or leave it unchanged on the FTP server.
Fiscal YearAn accounting period covering 12 consecutive months over which a company determines earnings and profits. The fiscal year serves as period of reference for the company and does not necessarily correspond to the calendar year.
FormulaSpecific computation method that determines the amount of compensation to be paid for the transaction being processed, such as split, flat, tiered, and expression; formulas can be associated with either a Schedule Detail or Schedule Grid.
GapThe client may define a time span that must exist between a customer’s previous expiration date and the new enrollment date in order to classify the new enrollment as "new" business. This time span is referred to as a gap in coverage.
Global Transaction DefaultsTranDefaults; method to derive needed transaction data
Government PlansAdministered by insurance carriers in cooperation with a government agency, whether it be Medicare at a federal level or Medicaid at a state level; required the insurance carried to interact with government agency to exchange eligibility information.
GroupA customer type, which can be an employer or commercial group type business or association of membership.
Hierarchy StructureUsed to define a relationship group of broker/agents/managers that will all receive commission on the sale of a product even though they may not be the writing agent.
HoldsUsed to prevent payment of a commission; denial of payment
Broker holdA hold assigned directly to a broker with associated rules, date periods and reason. All of the broker’s transactions that meet the rules and date periods will be held for the assigned reason.
Global holdA hold that is not assigned directly to a broker but has associated rules, date periods and reason. All transactions are compared to the date periods and rules. If the transaction matches the global hold, the transaction is held for the assigned reason.
Import FormatsA function within APMe used to import flat file data into the staging tables
Inbound DataData received by the system in order to insure the correct producer gets paid the correct amount; including transaction data, customer data, broker data, policy data, dates, and so on.
IndemnityProtection or security against damage or loss. Protection, as by insurance from liabilities or penalties incurred by ones actions.
Internal BrokerA broker, producer, agent, etc. that is employed by the company who is calculating/paying the commissions. In a lot of cases, these individuals are paid a salary and limited commissions. The limited commissions will either be reduced rates or bonuses; Internal Rep; Internal Sales Rep.
LabelsValues displayed as field, form, and tab descriptions throughout the APMe application.
Logging LevelAn attribute that controls which messages are written to the APMe Application Log. The Logging Level can be defined globally via an Application Properties File or as needed via a few panels within (e.g. Payout). There are 4 levels of logging severity: Debug, Information, Warnings, and Errors.
Match RulesIndicates that the transaction must exactly match the match rule(s) assigned to the sequence in order for that sequence to be utilized.
Medicare Exclusion ListA list of brokers who are not allowed to sell Medicare products. CMS maintains this list. Clients are responsible for ensuring that the broker is not on this list.
MenuNavigational component within APMe displayed on the left navigation arranged in a tree display; menu items change based on the tab selected.
Open Enrollment Period (OEP)In healthcare, the Open Enrollment Period defines when existing business renews and contract holders can change their benefit selections without questions or family life event changes.
Original Effective Date (OED)The date which the policy becomes effective; the date which the customer is covered by the policy; this is identified on the related group information and may be used in commission processing.
Outbound DataOutputs; data calculated by the commissioning system and provided to the user, including statements, payout reports, vouchers, etc.
OverridesA term used to indicate that a broker is earning commissions for a sale based on his/her relationship with the writing agent or another lower level broker.
Pay CyclesSelection criteria that can be used by the Payout process to limit processing to a subset of Vendors. When specified, the Payout process will only generate commissions for the Vendors with a matching Pay Cycle.
Payment EntityThe recipient of a commission payment.
Payment ExtractsDelivers data to other systems; completed via report or XML file.
Payment PlansSchedule master and rules used to enforce compensation between the company and broker.
PayoutA core function of APMe; a task ran after posting of all transaction files for a specific period is completed; compromised of 42 sequential tasks that must be completed successfully for the payout to be finalized.
PerfHistoryPerformance history; APMe stores performance related information to either impact a Producer's commission amount or generate reports.
Per Member MonthsA term used to indicate that the broker is paid based on the number of members associated with the sale.
PeriodsA Fiscal Year is divided into multiple periods, defined via date ranges, to reflect the client’s billing period and premium periods. Some client’s may need 52 periods per year (weekly process) or 12 periods per year (monthly processing).
PersistencyPersistency is the measurement of membership retention over a period of time based on the contract holder count at the beginning of a period of time period divided into the ending period contract holder count. This measurement may vary depending on related factors (union status, group type, etc.) and commission plan designs.
Plan CoverageA term used by the client to classify the types of products/services purchased by the customer. The Plan Coverage could be used to locate the appropriate commission rate for the transaction. Some examples of possible plan coverage values are Individual, Family, and Couple.
PolicyDate banded entity that associates specific details of the contracted product for a customer.
PortalsNavigational component within APMe; the top row of navigational options logically separates the system into high level sections.
PostAn action that performs edits against the transaction to determine if there are any errors. If a transaction is error-free, the transaction files are updated to reflect the error-free transaction data in the Integration portal. The transaction files updated by the Post process are TranHead and TranHis.
PremiumsA term used to refer to the amount that is paid to the client for the products/services provided to the customer. Premiums are typically paid monthly.
Premium ModalThis is the average monthly premium amount used to calculate prepaid commissions. The Premium Modal can be the first month’s Premium.
Premium PeriodDate for recognizing the effective date of the transaction; includes any activity date that will control the order of the commission system processing (benefit period, date of enrollment, date of sale).
Prepay/AdvanceA term used when commissions are paid in advance of receiving all of the actual Premiums.
QB QueryA record that stores hard-coded SQL queries that can be stored and re-used, such as for extracts or reports.
Quick searchA search method using a search bar located at the top right of the screen; used to return searches on menu items; search results may change based on menu selected.
Rapid DisenrollIf a member terminates within a predefined enrollment duration, the client may consider that termination as a Rapid Disenroll, which may allow the client to assign different chargeback rules.
ReciprocityA reciprocal agreement where one state recognizes the license or appointment of another state.
ReinstatedA Member/customer is reinstated after terminating in error or prematurely.
Renewal BusinessAfter the first year of enrollment, the customer will be classified as "Renewal Business". Clients often pay one commission rate for new business and a different commission rate for renewal business.
Report FormsProvides the functionality for the client to define forms, present report content, and define dashboards that are custom to a client’s needs.
ReservesProvides the means to withhold minimum and maximum balances in a reserve account; used to offset negative commissions by dispersing the full amount from the reserve balance if possible.
RetroactivityAny change made in the commissioning system relative to configuration data or inbound transaction data that can cause the need to reexamine previously processed commissions; system changes that result in historical commission re-evaluation.
ScheduleA group of rules used to enforce the compensation agreement between the client and the broker; consists of one or more schedule grids and one or more formulas.
Schedule GridA single compensation rule that defines the field values that will be compared to the transaction in order to locate the best match; all schedule grids associated with a schedule will be searched until the best match is identified to compute the commission amount.
Schedule TypesA value assigned to the Schedule to indicate how the best matched compensation rate will be identified. There are three schedule types, Grid, Match Rules, and Weighted.
SQL ScriptsProvides the ability to manipulate data during certain process events (e.g. Before Post, Before Computation, etc.). SQL Scripts may invoke a single SQL Statement or a SQL Stored Procedure.
SQL WorkbenchProvides the ability to query the client’s database without requiring direct access to their database server.
Staging TablesHolding tables used to store imported data until posting. Also known as InFiles.
StatementA report of commission activity designed to present to the Vendor; provides details behind payments or chargebacks of money.
TabsNavigational components within APMe located on the second row under portals. Tabs are specific to the portal selected and change as you navigate between portals.
Term With/Without Cause"Terminated With Cause" and "Terminated Without Cause" are phrases that may be used to indicate when a chargeback is desired. "Term With Cause" may require a chargeback, whereas "Term Without Cause" may not require a chargeback.
TerminationA term used to indicate that an entity is no longer valid for processing as of the specified expiration date.
TransactionThe entity that may trigger a commission payment.
Transaction DateIdentifies the date of sale or effective coverage period associated with premium payment; represents the chronological order of transactions associated to customer payments.
True-UpA process that compares an expected result with an actual result and adjusts the commissions accordingly. Clients may have different True-Up processes based on their business needs.
Upline ProducerA broker who may earn commissions based on his/her relationship with one or more downline producers.
ValidateAn action that performs edits against the transaction to determine if there are any errors.
VendorThe individual or group which receives payment for a broker’s commissions. Also called a Payee.
VoucherA summary of the vendor’s compensation, which includes the net amount to be paid and the previous balance, current commissions, and manual adjustments used to derive the net amount to be paid. Because APMe does not generate a check or submit an Electronic Funds Transfer request, the Voucher information is typically extracted in a format that the client can use to request payment via another source.
Writing AgentThe broker that sells or contracts the business with the customer. The Writing Agent may be an Internal Rep or an External Rep; Broker of Record (BOR).

Insurance Terms and Abbreviations

AbbreviationDefinition
PBPPlan Benefit Package
MMR

Monthly Membership Report

CMS Payments and Adjustments by Member (Part C and D members)

MPWR

Monthly Premium Withhold Report

Beneficiary Premiums withheld from Social Security for Part C and D coverage

TRR

Transaction Reply Report

Status of a health plan’s CMS transactions for reconciliation of membership including changes not initiated by the plan (e.g. member disenrollments)

SPAPState Pharmaceutical Assistance Program
LISLow Income Subsidy
Dual EligibleIndividual that qualifies for Medicare and Medicaid
Medigap

Medicare Supplement. This is coverage for individuals with Traditional Medicare. These plans typically cover medical expenses not covered or partially covered by Medicare.

Medicare Select – another type of Medigap policy (utilizes Managed Care – HMO networks)

Part AMedicare hospital coverage
Part BMedicare Medical and Outpatient coverage
Part CMedicare Advantage (Part A and B coverage)
Part D

Stand alone Prescription Drug Plans

Some enrollees may have Medigap coverage and PDP coverage

MAMedicare Advantage
MAPDMedicare Advantage – Prescription Drug
PDPPrescription Drug Plan
MSAMedical Savings Account
PFFSPrivate Fee For Service
MCOManaged Care Organization
MARx Report

Medicare Advantage and Prescription Drug System Report

Agent Broker Compensation Report – establishes status of new or renewal and the six year cycle for the enrolled members. Plan may elect to pay compensation beyond the six year period.

January report has new, prospective and continuing enrollment

Subsequent months only have new enrollments

CMS Contract NumberAn identifier to each contract that a Medicare Part D plan has with CMS.
SNPSpecial Needs Plan
HICNHealth Insurance Claim Number
NIPRNational Insurance Producer Registry; A partnership that supports the work of US states and the NAIC in making the producer-licensing process more cost-effective, streamlined, and uniform for the benefit of regulators, the insurance industry, and customers.
NAICNational Association of Insurance Commissioners; a US nonprofit organization that helps develop model laws for state insurance regulators.

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