HEALTHCARE TERMINOLOGIES
What is deductible?
is a set amount of $ that the member has to satisfy before the insurance starts paying
Tool to check to cross check benefits and cost
EOC
What are the three statuses of Claim?
PAID
REJECTED
DEDUCTIBLE
PCP Stands for?
Primary Care Physician
This is the main tool that we use when assisting member.
SOLCEN
What is the other term for pre-authorization?
pre-certification
Family amount can be satisfied by any combination of family members but an individual would never satisfy more than their own individual amount.
Embedded Deductible
This is the tool to check the image of a member submitted claim
WCF
What do we call the unique provider identification number?
NPI
This is the tool we check the status of Member ID card
ESRD stands for?
End Stage Renal Disease
Give one example of a covered benefit for both INN and OON.
Emergency
What are the two types of claims?
Professional and Facility
A policy that requires to have a PCP assigned.
HMO
This is the tool we use to check our schedule in Nesting and Production.
NICE IEX
A spending account that a member can no longer access after leaving their employer.
HRA
Heath Reimbursement Arrangement
If the member is unaware of the Provider network status, what benefits should you provide?
What do we call a claim that was rendered outside the member's policy state?
ITS Claim
Groups of Doctors and medical offices that provide a range of services. PCP providers, Imaging Center, Lab, Specialist Doctors
Primary Medical Group / PMG
This is the pathway in CA MF to lock an account
BA >> AA >> ID#, CD >> active account >> F9
DMHC stands for?
Department of Managed Healthcare.
What is the Definition of CPT Code
Current Procedural Terminology
What are the three claim formats for an ITS Claims
Submission Format
Disposition Format
Reconciliation Format
What is the source of truth for checking provider status?
Research Provider
This is the tool we use to check if the Procedure Code is Medically Necessary
OMPTA