Authorizations & Refferals
Medicare Basics
Benefits
HIPPA
v CRM Service
CRM
100

what needs to be on file before a doctor visit?

Refferal

100

What does Part A consist of?

(Hospital Coverage)

Inpatient care

Skilled nursing

facility care

Hospice care

Home health care

100

Hospital Services fall into what three categories?

  • Inpatient
  • Outpatient
  • Emergency
100

THREE elements needed to verify member

  • Member     ID number(account number , Medicare id number will be shown on the     red white and blue card !! (Starts w/ an "H" w/ 8 numbers)
  •  
  • Member DOB
  • Member zip code
  • Member group name,     group number , or product type if needed
100

How to search a member?

Use member id number (H number w/ 8 numbers do NOT need last 2 zeros, Medicare id Number or SSN IF they give it to you)

If no ID number use first / last name , DOB , state & zip

200

Permission from Humana to obtain a service is?

Authorization

200

what is the Date of Birth Rule

If potential Medicare member’s birthday falls on:

  • 1st day of the month,     benefits begin on 1st day of the

previous month.

  • 2nd through end of     month, benefits begin on the first day

of birth month.

200

different categories of therapy?

Speech

Chemo

Occupational

Physical

cognitive

200

Provider verification?

  • Member id
  • Member DOB

Or

  • zip code

Also

  • TIN#
  • NPI#
  • Pharmacy ID#
  • Medicare ID#
200

what is used to locate a pharmacy ?

NPI #

300

this comes from a doctor to see another doctor




referral

300

what is Part d?

Prescription Drug Plan

Must have Part A or

B to qualify.

Helps cover cost of

prescription drugs

300

Examples of Hospital Services ?

  • ER visits
  • Inpatient admissions 
  • x-rays
  • lab work 
300

what is a Special circumstance ?

Individual requests member PHI on an incapacitated or incoherent member

Identify the relationship to member, have them verify member

And release the information as requested 

300

Whats needed to Search a Providers office?

Go to provider search tab

9 digit TIN or

10 digit NPI

400

hmo plans require this

referrals

400

What are the different Medicare Advantage Plans

HMO,     PPO,

PFFS, SNP, and MSA 

 

400

Who are the Ancillary Providers?

  • pathologist (labs)
  • anesthesiologists (crna)
  • radiologist
  • ER Physician
400

Restrictions of CONSENT FORM?

  • Valid for 2 years from signature date , except certain states: ca,ct,ga,il,ma,md,nj,nv,nc,oh,or. These are only valid for 1 year
  • No longer valid if member deceased
  • Only able to share information not make changes
  • Check for exclusions (certain information unable to share, can find in CRM)
400

Calls(PLANS) you take?

Mer= Hmo

Mef=pffs

Mro=pos

Mep=ppo

Pdp=prescription drug

MAPD = Medicare advantage prescription drug(medical and drug benefits)

MA= Medicare advantage (medical only)

PDP= Prescription drugs only 

500

this has 3 different types. name 3 types.

authorizations

future

current

retroactive

500

Who is eligible for medicare?!

  • People 65     years of age & older OR
  • People 65     years of age & older who worked or have a spouse

who worked for at least 10 years in a Medicare-covered Employment OR

  • People under     age 65 with     certain disabilities OR
  • People with End Stage     Renal Disease (ESRD) – permanent

kidney failure treated with dialysis or a transplant

500

how many tiers are on the Formulary list and are they generic or preferred?


Tier 1-     preferred generics (lowest cost, or zero $)

Tier 2-     generics (more $)

Tier 3-     preferred brand

Tier 4-     non preferred brand

Tier 5&6-     specialty (most expensive)

 

500

difference between POA and EOE?

POA- Member alive

EOE-Member deceased(eoe a type of poa)

500

what calls (plans) do you transfer?


MGR=group medicare hmo

MGP=group medicare ppo

Mgf=group medicare pffs

Den=dental plans

Mcd=medicaid

Mes=medicare supplement

Hmo,ppo= if hmo or ppo is listed in the product type for commercial

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