Maternity/Infertility
DME/Diagnostic Services
Pediatric Services/Pharmacy
Mental Health/Substance Abuse/ Short term Therapies
Preventive Services/Bariatric Surgery
100
These are the acceptable length of stays without pre-certification for a vaginal delivery and a c-section
What is 48 (vaginal) /96 (cesarean)
100
Equipment can be considered DME when......
What is 1. When the device is approved by the FDA and is primarily used for a medical purpose 2. When a device can withstand repeated use. 3. When the device is appropriate for use at home.
100
Pediatric Vision benefits are embedded into the medical plan, and applies to.......
What is children under age 19.
100
This 2008 law required group health plans and insurers that offer mental health and substance abuse (“MH/SA”) benefits to apply the same treatment and financial limits to these benefits as to medical and surgical benefits.
What is Federal Mental Health Parity
100
True or False. Preventive treatment out-of-network will be denied as not eligible for seperate reimbursement if not state mandated.
What is False Preventive treatment out-of-network will be denied as NON COVERED if not state mandated
200
This member liability is applied to global maternity benefits
What is deductible and coinsurance
200
PPA is required for some DME items or if the equipment would cost more than this amount.
What is $1500
200
This type of drug features the lowest copayment under basic formulary pharmacy classification
What is Generic Drugs.
200
Services related to this are covered as of 7/1/14; however are subject to any applicable PT/OT/Chiro or Speech therapy limits.
What is stammering and stuttering
200
Members and/or providers should be directed to this medical policy to get more information on requirements for Bariatric surgery.
What is "Surgery for Morbid Obesity"
300
The lifetime maximum for drugs and treatment on an IGO (grandfathered) policy for infertility is __________.
What is $5000
300
This program seeks to manage costs while ensuring that members get the right test at the right time.
What is the Diagnostic Imaging Management (DIM) program?
300
Pediatric dental coverage will run through this day for a member
What is the last day of the month of their 19th birthday
300
***TRIPLE PLAY*** From the Short Term Therapy PowerPoint, these are considered "other therapies"
What is Cardiac/Pulmonary Rehabilitation*no visit limit, Chemotherapy, Radiation therapy, Dialysis
300
These state-mandated benefits are also Health Care Reform mandated benefits and will be covered at 100% on non-grandfathered HCR compliant plans in all places of services except the Emergency Room or Inpatient:
What is gynecological exams cervical cancer screening ovarian cancer screening mammograms (regardless of diagnosis) colorectal screening (colonoscopy) bone mass measurement prostate-specific antigen tests newborn hearing screening
400
This medical policy is used to map out the guidelines for reimbursement to providers for maternity claims.
What is What is "Guidelines for Global Maternity Reimbursement.”
400
This must be the primary diagnosis for breast pumps to be covered.
What is lactating mother
400
This website allows you to get information on whether a drug is covered under a particular plan or not?
What is myPrime
400
Prior Review is required for these services through Magellan for both Individual and Group plans.
What is Inpatient, Outpatient and Intensive Outpatient
400
Patty Mayo had her annual wellness visit today and was told she is considered morbidly obese. She calls BCBSNC to get benefits and all relevant information for weight loss surgery which her PCP will monitor and the surgery will be inpatient-INN. What benefits/information should she be quoted?
What is PCP Copay for evaluation and treatment of obesity, Hospital Services- Inpatient, Prior Review requirements (2 PPAs are required for the surgery itself and the hospital stay) info about Blue Distinction centers, Nutritional Counseling Benefit
500
True or False. Elective abortion services are covered for all ACA compliant plans.
What is False Elective abortion benefits will not be covered for 2014 and going forward. We will still cover for services in cases of rape and incest to be determined by the diagnosis submitted on the claim. (Individual grandfathered plan coverage for abortions is not changing).
500
***DAILY DOUBLE*** This is the Call flow for Diagnostic services.
What is  Determine type of test and POS  Determine if Routine or diagnostic  Quote benefits based on type of test and POS  Adv no referrals required/if pre auth is required once CPT code is obtained
500
***DAILY DOUBLE*** Coverage for hardware under Pediatric Vision is:
What is (1) pair of lenses and frames OR one pair of non-disposable contact lenses per benefit period.
500
Residential treatment is only covered for ( ). Coverage is not provided if related to Mental Health.
What is Substance Abuse
500
Specialty care areas in Blue Distinction Centers/ Blue Distinction+ Centers include:
What is Knee and Hip Replacement Bariatric Surgery Cardiac Care Complex and Rare Cancers Transplants Spine Surgery
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