BENEFITS
The amount a member pays before the health plan begins sharing costs.
What is a Deductible
What is a service that may require prior authorization other than MRI?
PET SCAN
CT SCAN
SURGERY
You would start here to verify active coverage.
Where is Eligibility?
"How much is left on my deductible?
What are accumulators?
Before discussing any member information, this must be completed.
What is HIPPA?
A fixed amount a member pays for a covered service.
What is a Copay
This status means the request is still under review.
Pending Status
Where is COB (Coordination of Benefits)?
What is the member Claim info screen
"Is my CT SCAN approved?"
Where are Authorizations?
A member says they moved and need to update their address. What should you do first?
What is SU?
The percentage a member pays after the deductible is met.
What is a Coinsurance
If a PA request is denied, the member generally has this right
What is the right to appeal? .
Where is Claims?
What is Web claims?
What is SU?
What is CPS?
"I received an EOB showing my claim was denied. My provider says they submitted everything correctly, and I already met my deductible."
What are the three areas you should investigate?
What are Claim Details, Denial Reason, and Benefits/Accumulators?
A member says their doctor's office cannot verify coverage. What two things should you review?
What are Eligibility and Effective Dates?
What percentage does the plan pay for home health IIN for member ID G44966817
75% based on plan allowance
This process determines if certain services, procedures, or medications must be approved before they are covered.
What is Prior Authorization?
You would navigate here to locate authorization status.
What is SU
What is CPS
What is still under review and has not completed processing?
A claim is showing "Pending."
A member says they never received their ID card.
What is request a new ID card
Are wigs and hair pieces covered by the plan Member Id G44966817
Covered
Who submits a PA
Doctor
Where do you Find Benefits?
What is HPDB
Why do I have a higher member responsibility?
What is out of network?
"I received a letter from the health plan and don't understand it."
What is Doc 360?
What is the letter Center?