Eligibility
Loss of coverage, birth, and marriage are examples of this regarding enrollment.
Qualifying Life Event
True or False: Employee Assistance Program (EAP) is covered based on the members copay, coinsurance, and deductibles.
False- EAP is is 1-8 sessions per year that range from 20-30 minutes via telemedicine and are covered at NO COST to the member.
True or False: You can see medical authorizations and notifications in ISET.
True: The notification tab can be found under the claims tab in ISET
This resource is found in Knowledge Library to assist with any claims questions
Claims Advocacy
This is the FedEx vendor for the FSA, Dependent Care Flex Accounts, HRA, HSA, Commuter and Parking Benefits.
Optum Financial
This is the day of the week that the eligibility feed is sent to us from FedEx
Tuesday
This application/website is used to look-up pharmacy benefits, claims, and prior authorizations/ overrides.
Optum Navigator
What is the name of the group that handles MAJOR diagnostic testing, IE MRI, CT scans, PET scans, Etc.
Evicore
This tab in ISET shows the following amounts: non-covered, billed, allowed, copay, coinsurance, deductible, total member responsibility, etc.
Synopsis tab
This Service will penalize the member $1000 if they are not consulted before the following 5 surgeries: Spine, Hip replacement, Knee replacement, Weight loss or Hysterectomy?
________ is a federal law allowing employees to temporarily keep benefits coverage after employment ends or if they lose coverage.
COBRA
True or False: Regarding therapy limits, if a member's benefit plan (IBAAG or AVA) says they get 25 visits per year, they are allowed to request additional visits past their 25 visit limit.
False- IBAAG or AVA must specially state that after their 25 visit limit, additional visits may be requested based on medical necessity, in order for the plan to allow extra visits.
This icon is located in ISET header. When you hover on top of it, it will advise is prior authorization is required for radiology, cardiology, genetic testing, etc.
Med Nec Icon
3 filters/ ways to search for a claim in ISET
Claim number, Date of Service, Providers TIN, applying to deductible, applying to OOP
The three funding arrangements that are found on the eligibility tab in ISET. (acronyms are acceptable)
FI, ASO, and MMP
True or False: We do not coordinate with Medicaid.
True
Type of plan where the member has a higher benefit above regular INN benefits. These providers have been reviewed for Quality and Efficiency and are considered "the best".
Tiered Level Plan
This is a tool located under the star drop down in ISET where you can check if CPT codes require an authorization.
Notification Gateway Tool (NGT)
Claim closure status that is used when additional information is needed. For example: FWA records, MCR records, COB updates, etc. Hint: EOB is not generated, only a letter requesting that information.
Closed
Scripting that is used for when member calls in with related questions pertaining to disability claims and LOA requests.
"I have a team member who specializes in (benefit that member is calling about). Do you mind if I conference my team member in so that we can both help you get your questions answered? I will put you on a brief hold and then bring my team member on the line."
Three ways you can search for a member in Benefit Connect.
First/Last Name
SSN: (Social Security)
EEID: (Employee ID)
Remark Code used for denied claims for UHC members during the subrogation process for reimbursement.
XA
This can be used when you would like an OON provider to be considered at the INN due to the fact that no INN providers able to perform the services within 30 mile radius.
GAP Exceptions
When a member has a financial concern about a claim and the claim is correct.
Fee Negotiation
Job Aids that are used to handle daily calls to assist members.
FedEX BA
FedEx PSG
FedEx OHCA
KC/KL