Products
Most common and easily recognized Aetna product, Preferred refers to the use of providers that are in the Aetna PPO network.
PPO Open Choice
These 2 IDs are required element in HIPAA standard transactions.
NPI and TIN
The participating Aetna network that is affiliated or assigned using the geographic area of the member.
Home Network
____ is a predefined dollar amount that must be paid by the member toward the cost of covered services before the plan begins to pay benefits.
Deductible
The primary policy holder, usually the employee, also known as subscriber.
Insured
______ is an HMO-based product that’s processed on the ACAS platform which has same plan design as Managed Choice plan has two levels of benefits, referred and non-referred
QPOS on ACAS
the responsible party who is "sponsoring" the insurance plan, they select the benefits for their plan, choosing from the standard plan benefits or customized benefits.
Plan Sponsor
Name 4 plan/ product names that are under MEPO Network
Aetna Select, Elect Choice, Open Access Aetna Select, Open Access Elect Choice
Some plans require PCP selection, the selected PCP can submit _________ to Aetna electronically or on paper.
Referrals
The time period, for which the insured can choose new/different insurance, add/remove dependents or make changes to a plan.
Open Enrollment
A standard plan feature for plans that require a referral. This feature allows members access to certain medical services and specialists without a referral.
Direct Access
The method by which claims and/or premiums are funded and paid.
Funding arrangement
Term explaining how networks reciprocate or partner up. It is about the relationship that two networks have even though they may be written in two different markets.
Reciprocity
_____ is an add-on feature that a plan sponsor can add on to one of the managed plans that gives members greater freedom because it waives the managed component of these plans.
Open Access
Many states have regulations or benefit plans that require us to provide coverage for ________ from birth through the 30/31 days of life.
Newborn
The _________ plan is an add-on plan that works in conjunction with the member’s base medical plan. The purpose is to pay out services the member is covered for....
Executive Medical plan
The dollar amount over what the participating provider billed vs. what the contracted rate is
Write-Off
This is when there are not enough contracted providers within a geographic area to service the amount of membership.
Network Inadequacy
____ is the process of verification of a provider's professional qualifications to determine if the provider meets certain criteria relating to professional competence.
Credentialing
There may be times when the provider information you need to check is not available within ASD. You can access EPDB in RUMBA.
EPDB stands for
Enterprise Provider Database
known as the Patient Protection and Affordable Care Act (PPACA) was signed on March 23, 2010. will expand the availability of health care coverage to millions of Americans.
Health Care Reform (HCR)
A method of payment where provider is paid fixed amount based on the number of members they service, not on the number of services they provide.
Capitation
_____ is a nationwide program developed to reduce medical costs by providing contracted rates for many indemnity and out-of-network inpatient and outpatient hospital claims as well as physician claims.
NAP / National Advantage Program
A specific dollar amount that can be paid on covered services during an individual's lifetime
Lifetime maximum
What screen do you need to go in EPDB to determine network participation of provider especially if they have multiple Tax and addresses associated
NV screen