Medicare Advantage
(HMO)
(HMO)
In order to get the information for billing details I must launch this in Maestro
What is PMG detail?
This system is used when members are requesting 2024 provider directory, formulary, EOC, and or pharmacy directory
What is the MACRO?
To obtain DME supplies and have it covered by insurance, member must have this
What is a prescription/ order?
This site can help when searching for OON providers that are contracted with Medicare.
What is Medicare.gov?
Flu (influenza), Pneumonia (pneumococcal), Hepatitis B, Other immunizations that are directly related to the treatment of an injury or direct exposure to a disease or condition (e.g. Rabies, Tetanus, Diphtheria, etc.)Covid boosters are covered under this portion of Medicare
What is Medicare Part B?
These will open up a screen to show you who is responsible for payment for medical services
What are binoculars?
Members often request a paper copy of this document during AEP. This document can be requested thru CAMP.
What is an Annual Notice of Change (ANOC)?
This time period is aquired before DME supplies can be considered purchased
What is 10-13 months?
Caller states they are POA of member, Maestro does not reflect caller as POA. Caller is persistent that documents have been submitted. This system will show if documents have been received.
What is VIEW?
Highly requested by members this vaccine is covered under Part D and is covered at $0 for BOTH injections.
What is the shingles vaccine (Shingrix)?
Unfortunately, UHC cannot make everyone happy, these two PMGs will be parting ways starting 1/1/2024
Who is Sutter Medical Group?
Who is Canopy John Muir?
New in 2024: $0 member cost-share in the Catastrophic Drug Payment Status for Medicare Part D covered drugs.
What is the Inflation Reduction Act (IRA)?
What is Coverage summaries?
Member states they have requested iFOBT kit to be sent to home address. Member states this request has been over 30 days. After verifying their mailing address, advocate can request another kit to be sent on this system.
What is Sharepoint?
Member has been in ER and is now getting notice of denial for Self-Administered drugs. This form would need to be sent in order for drugs to be processed under their Part D plan.
What is a RX DMR?
PCP change requested between 25th and end of month: Standard effective date will be the 1st of the month following next
Who are California members only?
Non-prescription (over-the-counter) hearing aids will be offered for groups exclusively through UHC.
What are 2024 Hearing aid benefits?
Covered under the Medicare Part B Diabetic Monitoring Supplies benefit and cost share, when supplied by a DME provider or participating pharmacy. DO NOT quote DME cost share.
What are Continuous Glucose Monitors (CGMs) and their components?
Member calls to check status of DMR, reviewing medical claim history does not show DMR claim, this system is another way of verifying if the DMR forms were received
What is Doc360?
To determine whether a member's diabetic supplies and services are covered under Part B or Part D, one should review this job aid.
What is prescription coverage Part B vs Part D?
In order for member to see an OON provider, this document will need to be submitted for consideration
What is an MIOD?
Member inquiring about possibly opting out of plan but would like to know if they are elgible to opt back in the following year, this information can be found here
What is the GRIF?
If no DME providers are in members surrounding area, this list would be the next step in searching for providers
What is the National DME providers list?
While reviewing formulary for member, there is notification that medication requires PA. This system can be used in order for members to intiate PA for their prescribed medication?
What is the Prior Authorization System (PAS)?
The stage between the member meeting the Initial Coverage Limit and prior to meeting True Out of Pocket (TrOOP) cost. The member is responsible for 25% of their drug costs.
What is the Coverage Gap?