1
How many active groups does the ASO LOB have?
What is an amendment?
An update on a plan document that needs to be read at all times.
What is the first thing you have to read in a plan document BEFORE giving out any information?
READ ALL OF THE AMENDMENTS!!!
Can we update a members demographic information? if so, how?
yes, If member needs name or DOB changed we can go ahead and do so, they will have to change it with their HR first and they have to send their birth certificate and ID to us and we will send it to Enrollment. Address, Phone and Email is just like COMM LOB.
Will ASO pre- certifications go to Evicore?
No, they will all go to Prominence.
What does MA stand for?
Maximum Allowable
What is a maximum allowable?
The opposite of MOOP. Members have a specific OON coverage, once they exceed that amount, member will be responsible for 100% of the total cost.
COMM: How many hearing aids are members limited to?
1 pair per 3 years.
What Does ASO Stand for?
Administrative Services Only
What is the birthday rule?
The parent who's birthday comes first will be the policy holder.
Who is our dental vendor?
Guardian Dental
What is the proper name for Prior Auths in the ASO LOB?
Pre- Certification or Utilization management
What do we tell a provider if they ask if we cover a specific CPT code?
"We go by description and not by CPT code"
What does FH Network stand for?
First Health
Whos is our Pharmacy Benefit Manager?
Maxor Plus
Where can you find any exclusions for a benefit?
EOC/ COC in Sharepoint
Who uses our FH Network?
Members outside of NV (Remotely)
What is another way you can very exactly how many times a member has received a specific service/ CPT code?
Service History tab in QNXT
Where can you find a plans timely filing?
In their plan document.
Does a baby automatically get covered by the plan?
Once the baby is born, the hospital sends us the face sheet. The baby is then added onto the account, but as their own just as any other dependents are. the baby will then be a covered dependent for 30 days, if the Parents don't add baby onto the policy with their HR then the baby is no longer covered with PHP. The baby will always have their own account, with their own claims, and their own benefits.
What is our appeals timely filing?
180 from EOB
Who uses our UHN network?
Members located in NV.
Is missing tooth clause covered in the City of Reno?
plan doc will read no which means there is no clause meaning it'll be covered.
What does UHN stand for?
Universal Health Network
Can we send the dental breakdown to a provider?
YES