Plan types
PPO-Preferred Provide organization is the only plan that pays the least out of pocket?
True
Coinsurance
Coinsurance is a set percentage of service costs that you will be expected to pay once you have met your annual deductible. When your annual deductible is met, your insurance provider pays for their portion of the full cost of the service and you pay the coinsurance, or remaining percentage.
HIPPA is not used for verification
True or False
False
What do we conside as Demographic updates?
Address change
Name change
What questions would we use to ask probing questions?
5 Ws and 1 H.
What?
When?
Why?
Where?
Who?
How?
List the PPO benefits
-Offers both in and out of network coverage
-Deductibles, co-insurance and copays
-Pay less out of pocket
Copay
Copayments or copays, are pre-set dollar amounts you are expected to pay for office visits, procedures or prescription drugs under your insurance plan. Once the copay has been met, typically, the insurance company pays all remaining costs.
Which TAB is exclusively used by Accolade clinicians?
The care tab......
What happens if a prior-authorization is not obtained before the service is rendered?
The member's claim may be denied or the health plan may apply a penalty to be paid by either the provider or the member themselves.
True or false
A prior-authorization is not a guarantee of benefits and is strictly confirming the medical necessity of the treatment, procedure or test.
True
What is the health savings account for on the high deductible health plan?
-To offset the cost of the deductible
Deductible
A deductible is the amount you pay out of your pocket before your insurance starts to pay its share of the costs. It does not include your employee per pay contributions. The deductible runs from January 1 through December 31 each year. Once you have met that dollar amount, you have met the requirements for the plan year.
True or False
The Provider tab is the 6th tab in InView.
False
The Provider tab is the fifth tab in InView.
Does the types of services that require a prior-authorization/pre-certification as well as the process to obtain an authorization differ between customers and health plans
Yes
Name the 4 -Quality life events
Marriage
Divorce
Child adoption/birth
Job status change
-EPO does not have OON coverage?
TRUE/FALSE and substantiate
TRUE except if it's an emergency
Allowed Amount
The maximum amount a plan will pay for a covered health service. May also be called "eligible expense," "payment allowance," or "negotiated rate."
Which of these are you not able to see in the HISTORY TAB
who has been in this record previously
attachments uploaded by nurses and PCPs
progress being made on a task
notes previously taken by AI and/or humans
attachments uploaded by nurses and PCPs
Name 3 Employee sponsored health plans?
-PPO
-HDHP
-HMO
Name 4 common examples of services or items that may require a prior-authorization?
Advanced Imaging (MRI, CTSCAN, PET SCAN)
Inpatient services (medical & behavioral health)
DME (durable medical equipment)
Sleep studies/therapies
Surgeries/procedures
Pain management procedures
Rx (high cost medications)
True or False
POS-Point Of Service plan does not require a referral?
False
-May require a referral
Balance Billing
When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30.
Which tab houses benefits information (from acupuncture to x-rays and everything in between), enrollment data, and all programs a member can access through Accolade and/or their employer.
Benefit Tab
What does Quoting a full benefit mean?
You educate a member on all of their options, the In Network (INN) benefit, Out of Network (OON) benefit (to include the Out of Network provider's ability to Balance Bill), subservices (routine and non-routine) and any provisions.
Name 3 things that Health Assistants and nurses can confirm in the UM Claims tab?
The prior-authorization was received by the health plan
The date the prior-authorization was submitted to the health plan
The initiating provider (who requested the prior-authorization)
What the prior-authorization is approved for
The medical necessity reason (diagnosis)
The determination of the prior-authorization
If approved, the start and end date of the approval