Compliance & Regulations
This is a U.S. federal law designed to protect sensitive patient health information and ensure its secure handling by healthcare entities.
What is HIPAA?
This is the time frame for AEP 2026.
What is October 15 to December 7, 2026?
This is how we measure success during AEP.
What are member satisfaction scores and enrollment accuracy? UES.
Which tier levels will have deductibles this 2026 year
Tier 2 thru tier 5
This is the most important factor when helping a member choose a plan.
What are their health needs and preferences?
This is the consequence of giving incorrect plan info.
What is a compliance violation or CMS audit? (CTM)
This is TAB to verify member's plan for 2026 and if it is the same plan as the current plan; check the contract, PBP, and segment number for the next year’s plan with the current plan.
What is Plan Tab?
This is the best way to support teammates during AEP.
What is clear communication and collaboration? help on the chat by sharing SOPs
This is the form used to officially enroll a member in a new plan.
What is an enrollment application?
This is what we aim to improve every year during AEP.
What is the member experience?
This is a request to have the plan change a decision for a denied prior authorization or claim.
What is Appeal?
This document outlines changes to a member’s plan for the upcoming year.
What is the ANOC (Annual Notice of Change)?
This is how we stay aligned and informed throughout AEP.
SOP, updates and change champ emails.
This is the timeframe when coverage changes made during AEP take effect.
What is January 1, 2026?
This is the key principle that guides every interaction during AEP, ensuring members receive accurate, respectful, and personalized support.
What is putting the member first?
When can we start discussing plan changes with existing members who have received their ANOC for 2026
What is after September 1, 2025?
This is the deadline for plans to send ANOC to members.
What is September 30?
This is how we prepare for AEP success.
What is training and reviewing updates daily?
This is a portion of medical expenses that a member (like a patient or insured individual) is responsible for paying out of pocket.
What is Cost Share?
This is what we do when a member is unsure about their coverage.
What is educate and guide member through options?
This is the formal decision a Medicare Advantage plan makes about whether a requested service or item will be covered or paid for.
What is an Organization Determination?
This is whether an eANOC can be sent again or used as a replacement.
What is no?
Replacements are sent via mailing address on file.
This is the best way to handle a tough call or situation during AEP. hint: SOP
De-Escalation Strategies SOP
This is now categorized as a comprehensive service, not a preventive one. Code applies to maintenance cleanings for patients who have been diagnosed with gum disease.
What is Periodontal Maintenance (Dental code D4910) is now categorized as a comprehensive service, not a preventive one?
This is the best way to ensure a member feels heard during a call.
What is active listening?