11 N.C. Admin. Code 18 .0114 - DEFINITIONS
As used in this Rule and in 11 NCAC 18 .0115, 11 NCAC 18 .0116, and 11 NCAC 18 .0117, the following terms have the meanings ascribed to them:
(1) "Claims
accrued" means that portion of claims incurred on or prior to the valuation
date that result in liability of the MEWA for the payment of benefits for
medical services that have been rendered on or prior to the valuation date, and
for the payment of benefits for days of hospitalization and days of disability
that have occurred on or prior to the valuation date, that the MEWA has not
paid as of the valuation date, but for which it is liable, and will have to pay
after the valuation date. This liability is sometimes referred to as a
liability for accrued benefits.
(2)
"Claims reported" means when a MEWA has been informed that a claim has been
incurred, if the date reported is on or prior to the valuation date, the claim
is considered as a reported claim for annual statement purposes.
(3) "Claims unaccrued" means that portion of
claims incurred on or before the valuation date that result in liability of the
MEWA for the payment of benefits for medical services expected to be rendered
after the valuation date, and for benefits expected to be payable for days of
hospitalization and days of disability occurring after the valuation date. This
liability is sometimes referred to as a liability for unaccrued
benefits.
(4) "Claims unreported"
means when a MEWA has not been informed, on or before the valuation date,
concerning a claim that has been incurred on or prior to the valuation date,
the claim is considered as an unreported claim for annual statement
purposes.
(5) "Claim reserves" mean
reserves or liabilities held for claims incurred on or before the valuation
date, but unpaid as of the valuation date. Claim reserves include both reported
and unreported claims. Claim reserves are established for both accrued and
unaccrued benefits.
(6) "Incurred
date" means the date that a claim is determined to be a liability of the MEWA.
For example, the charges for inpatient hospital and physician visits in
hospitals would be assigned an incurred date equal to the date of admission;
outpatient hospital charges would be assigned an incurred date equal to the
date of service; surgical expenses would be assigned an incurred date equal to
the date of the surgery.
(7)
"Unearned premium reserves" mean reserves established for premiums received
that produce insuring periods extending beyond the valuation date.
Notes
Eff. July 1, 1992;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 16, 2014.
Eff. July 1, 1992.
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