| Term | Definition |
| Active Quarterly Premium | A 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. |
| Agency | A 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 Related | A commission structure that uses the policy holder’s age to locate the commission rate. |
| Application Received Date | The 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 Period | Time 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. |
| Appointments | Accreditation 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 Date | The 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.). |
| Audits | Tracks 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 Period | Processing period; defines the current processing period within the system. |
| Bonus | A method for generating additional compensation based on achieving predefined performance goals. Bonuses are typically paid quarterly or annually. |
| Broker | The 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. |
| BrokerCustomer | Data entity within the database which describes/connects the relationship between a broker and a customer. |
| BrokerDetail | Data entity within the database which describes/connects all details associated to a broker record. |
| Brokered Groups | A term used to indicate that the group (customer) has an external broker as the writing agent. |
| Carrier | An insurance company that provides products and/or services in a specified geographical area. |
| Chargebacks | A 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. |
| Client | A company using products and/or services provided by SAP/APM. |
| CMS | Centers for Medicare and Medicaid Services (CMS). A US Government Agency that administers Medicare, approves/rejects Medicare applicants and pays portion of Medicare Premiums. |
| Codes | Values and descriptions stored within the Codes table are displayed as drop down selections throughout the APM application. |
| Commercial Plans | The traditional employer group or individual healthcare coverage that can be purchased directly from the insurer or through an insurance agent. |
| Commission | Compensation paid for selling products. May include a standard commission rate, a special broker fee, or a performance bonus. |
| Commissionable Premium | Premiums excluded from the commission payment processing. |
| Commission Caps | Imposed limits or "caps" on the total commission payments to producers for specific policies or groups. |
| Compensation Agreement | A 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 data | Data used to configure the commissioning system to meet the needs of the user (broker, payee, customer, schedule data) |
| Customer | Entity purchasing the product or service. |
| Data Dictionary | Catalog of terms and definitions found within APM. |
| Date banded | Date range; defines a start date and end date for data. |
| Department of Insurance | Each state has a Department of Insurance branch that is responsible for supervising and regulating the insurance business; may include awarding accreditation to brokers/agents. |
| Differentials | A 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 Producer | A broker who may trigger commissions for one or more upline producers based on his/her relationship with the upline producers. |
| Draw | Fixed or minimum payment amounts to brokers. |
| Earned Health Premium | Premium amount supplied by Underwriting on the group that is applicable towards commissionable premiums. This will be on the transactions for the group. |
| Effective Date | Date which any changes that need to be made to a commissions processing environment become effective. |
| Entity | Any piece of data or a table within the database. |
| Entity Edits | Provides the ability for the client to create Warning Messages or Error Messages to enforce their configuration rules. |
| Entity Summary Views | Users 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 Date | Date which any changes that need to be made to a commissions processing environment end or become expired. |
| Expression | A method to add logic (i.e. simple programming statements) to derive a value. Expressions are used throughout APM (e.g. Field Defaults, Entity Edits, Transaction Defaults, Formulas). |
| External Broker | A 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 Expression | Provides the ability for a Formula to compute a fee compensation amount (AmtFee) in addition to the base commission (AmtComm). |
| Fee for Service | A term used to indicate that the broker is paid a specific amount for the service provided. |
| Field Defaults | Maintains 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 Sweep | Many 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 Year | An 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. |
| Formula | Specific 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. |
| Gap | The 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 Defaults | TranDefaults; method to derive needed transaction data |
| Government Plans | Administered 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. |
| Group | A customer type, which can be an employer or commercial group type business or association of membership. |
| Hierarchy Structure | Used 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. |
| Holds | Used to prevent payment of a commission; denial of payment |
| Broker hold | A 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 hold | A 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 Formats | A function within APM used to import flat file data into the staging tables |
| Inbound Data | Data 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. |
| Indemnity | Protection or security against damage or loss. Protection, as by insurance from liabilities or penalties incurred by ones actions. |
| Internal Broker | A 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. |
| Labels | Values displayed as field, form, and tab descriptions throughout the APM application. |
| Logging Level | An attribute that controls which messages are written to the APM 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 Rules | Indicates that the transaction must exactly match the match rule(s) assigned to the sequence in order for that sequence to be utilized. |
| Medicare Exclusion List | A 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. |
| Menu | Navigational component within APM 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 Data | Outputs; data calculated by the commissioning system and provided to the user, including statements, payout reports, vouchers, etc. |
| Overrides | A 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 Cycles | Selection 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 Entity | The recipient of a commission payment. |
| Payment Extracts | Delivers data to other systems; completed via report or XML file. |
| Payment Plans | Schedule master and rules used to enforce compensation between the company and broker. |
| Payout | A core function of APM; 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. |
| PerfHistory | Performance history; APM stores performance related information to either impact a Producer's commission amount or generate reports. |
| Per Member Months | A term used to indicate that the broker is paid based on the number of members associated with the sale. |
| Periods | A 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). |
| Persistency | Persistency 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 Coverage | A 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. |
| Policy | Date banded entity that associates specific details of the contracted product for a customer. |
| Portals | Navigational component within APM; the top row of navigational options logically separates the system into high level sections. |
| Post | An 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. |
| Premiums | A 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 Modal | This is the average monthly premium amount used to calculate prepaid commissions. The Premium Modal can be the first month’s Premium. |
| Premium Period | Date 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/Advance | A term used when commissions are paid in advance of receiving all of the actual Premiums. |
| QB Query | A record that stores hard-coded SQL queries that can be stored and re-used, such as for extracts or reports. |
| Quick search | A 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 Disenroll | If 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. |
| Reciprocity | A reciprocal agreement where one state recognizes the license or appointment of another state. |
| Reinstated | A Member/customer is reinstated after terminating in error or prematurely. |
| Renewal Business | After 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 Forms | Provides the functionality for the client to define forms, present report content, and define dashboards that are custom to a client’s needs. |
| Reserves | Provides 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. |
| Retroactivity | Any 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. |
| Schedule | A 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 Grid | A 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 Types | A 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 Scripts | Provides 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 Workbench | Provides the ability to query the client’s database without requiring direct access to their database server. |
| Staging Tables | Holding tables used to store imported data until posting. Also known as InFiles. |
| Statement | A report of commission activity designed to present to the Vendor; provides details behind payments or chargebacks of money. |
| Tabs | Navigational components within APM 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. |
| Termination | A term used to indicate that an entity is no longer valid for processing as of the specified expiration date. |
| Transaction | The entity that may trigger a commission payment. |
| Transaction Date | Identifies the date of sale or effective coverage period associated with premium payment; represents the chronological order of transactions associated to customer payments. |
| True-Up | A 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 Producer | A broker who may earn commissions based on his/her relationship with one or more downline producers. |
| Validate | An action that performs edits against the transaction to determine if there are any errors. |
| Vendor | The individual or group which receives payment for a broker’s commissions. Also called a Payee. |
| Voucher | A 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 APM 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 Agent | The 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
| Abbreviation | Definition |
| PBP | Plan 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) |
| SPAP | State Pharmaceutical Assistance Program |
| LIS | Low Income Subsidy |
| Dual Eligible | Individual 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 A | Medicare hospital coverage |
| Part B | Medicare Medical and Outpatient coverage |
| Part C | Medicare Advantage (Part A and B coverage) |
| Part D | Stand alone Prescription Drug Plans Some enrollees may have Medigap coverage and PDP coverage |
| MA | Medicare Advantage |
| MAPD | Medicare Advantage – Prescription Drug |
| PDP | Prescription Drug Plan |
| MSA | Medical Savings Account |
| PFFS | Private Fee For Service |
| MCO | Managed 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 Number | An identifier to each contract that a Medicare Part D plan has with CMS. |
| SNP | Special Needs Plan |
| HICN | Health Insurance Claim Number |
| NIPR | National 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. |
| NAIC | National Association of Insurance Commissioners; a US nonprofit organization that helps develop model laws for state insurance regulators. |