Benefits
Plan is based from January 1st to December 31st and resets for the member on January 1 every year.
Calendar year
5 w's of a claim
Plan is based on the employer's plan year (i.e., July 1st - June 30th), and resets every the beginning of this plan year
Policy Year
Home delivery prescriptions
Mail Order
Introducing a caller before connecting to another department
warm transfer
Set dollar amount the member is required to pay for certain covered health services
co-payment
Tab to view why a claim was denied
Service line
Includes:
Pregnancy
A list of medications you can search in to identify the tier and benefits for every medication.
Formulary
hold protocol
Procedure/service that changes or improves appearance without significantly improving physiological function, as identified by UnitedHealthcare
Cosmetic Procedure
Remark code that indicates OOP was met
S6
(Non-network office-based lab/X-ray)
Diagnostic-based services ordered by a physician (generally because of an office visit), and performed by separate OON providers. Allows in-network processing for out-of-network claims under certain circumstances.
NOBLX
A custom made RX. The drug ingredients are mixed or adjusted to meet the patient's needs or modify how the drug is administered.
Compound Medicine
As we work to build strong relationships with each caller everyday, you are asked to select one member each week that made an impact on you. This demonstrates our United Culture Values of Relationships and Compassion by sending a personal written message to delight the consumer.
Compassion Card
Medical equipment that is all of the following:
DME
A member receives an invoice, bill, or statement from the servicing provider for amounts over what UHC identified to be patient responsibility.
Balance Billing
Provides access to discounts from the provider's charges when services are rendered by non-network providers that participate in this program.
Shared Savings Program
A plan-specific exception, which may allow prescriptions to be covered if special circumstances are met, such as vacations, armed forces, etc,; commonly used when a member needs an exception to fill a medication.
Override
A member requests consideration of a non-covered service
Benefit Exception
When a person is covered by two health plans, the process the insurance companies use to decide which plan will pay first for covered medical services or prescription drugs and what the second plan will pay after the first plan has paid.
Coordination of Benefits/COB
When UnitedHealthcare provides the secondary insurance, a payment is made only when the insurance benefit for the services rendered is greater than the benefit for the primary insurance.
COB non-duplication
One of the most common tools you use to promote healthy living
Advocate dashboard
M/I Days Supply **bonus points** for description
reject code- 19
Information needed when calling SME line