CLAIMS
Explain what adjudication means
Adjudication is the formal or legal process of resolving a dispute or deciding a case by a judge (Claim Department)
allows Medicare Advantage plans to offer specific supplemental benefits to members with chronic conditions. These benefits go beyond traditional medical services and are designed to support overall well-being.
Special Supplemental Benefits for the Chronically Ill
Specific range of ages used to group people together for data analysis, business planning, or pricing. In out LOB, it is for the catered ages of our providers.
Age Band
A geriatric physician consolation will charge the member
a PCP copay
RUMBA code for HMO Insurances
MEHMO
What are the two types of claim?
Professional and Institutional
are extra things that Medicare does not pay for. These are usually discounts. A _____ provider gives these to people in a Medicare Advantage plan. These are not part of the Member’s plan's benefits.
VAIS
What are the identifiers of an insurance plan
Contract number and PBP
Samples of Healthy Food
a 4 or 5-digit code assigned to network names
NET ID
Denial Code for Duplicate Claim
A114
program is a federal initiative that lowers prescription drug costs, deductibles, and premiums under Medicare Part D
Extra Help or Low Income Subsidy Program
Full form or expanded term of GPS
Guided Personal Service
Provide at least 5 stores that our members can visit to purchase their OTC items (Other Retail Locations)
CVS, Walmart, Albertsons, Kroger, Schnucks,Dollar General, Shaws, Giant, Bravo, ACME, VONS.
Rumba Code or ePolicies code for Pediatric Cardiologist
CC
Generally, hospice claims will be denied by our claims department. Provide an explanation
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Members can save ___ on select CVS-brand health and wellness items when shopping in-store
20%
built the first computer mouse in 1964 out of a carved block of wood with two small metal wheels underneath
Douglas Engelbart
Explain how we identify the primary and secondary insurances if the the member has COB.
By the number of employees (20)
Denial code 317
You plan does not cover services received, or drugs taken for a condition that you were treated for within 6 months before your start date with this plan. They are also, then, not covered for the first 12 months
A member is responsible for $180 copay for each day of INPATIENT stay, if the member stayed for 16 days, how much is the member's responsibility?
$2,880
"An amount added to a member's monthly plan premium if they did not enroll in a Medicare Advantage plan with Part D benefits or a stand-alone prescription drug plan when they were first eligible for Medicare Parts A and/or B, or went without creditable prescription drug coverage for 63 or more continuous days" This statement is correct, the question is what program in the Philippines can you compare with Medicare's "extra help" program.
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Birds share a common ancestor with non-avian dinosaurs and are classified as surviving ________
theropod dinosaurs
is a family-owned dental supply company. They offer simple, affordable, and Aetna-branded oral health products. These include:
Z Dental
Differentiate HCPCS and CPT Codes
CPT codes describe medical procedures and services performed by doctors, while HCPCS codes include those CPT codes plus a second level of alphanumeric codes for equipment, supplies, and non-physician services