HIPAA
How many pieces of HIPAA do you need to verify for each in-bound call?
3
What escalation would you create for member appeals or an expression of a dissatisfied member?
Complaints
What is an EOB?
Explanation of Benefits
If you discussed a PCP Copay on the call, what would be the appropriate ticket tag?
Benefits - Medical
What day is a Premium Payment due?
The 1st!
How many pieces of HIPAA do you need to verify for out-bound calls to providers?
2
If a member requests a supervisor, where would you post to get assistance?
Content Room
What is the "Journey of a Claim"?
Submitted, processed to determine coverage, then an EOB is sent out.
If you discussed a premium payment on the call, what would be the appropriate ticket tag?
Eligibility - Premium Payment
What program do we use to check prescription claims and authorizations?
What does HIPAA stand for? (what is the break down of the acronym)
The Health Insurance Portability and Accountability Act
What tool can you use to find INN providers?
Care Router
What specific number determines WHO is billing for the service on a claim?
Billing NPI
If you discussed a members claim, what would be the appropriate ticket tag?
Claims - General Inquiry
Who handles Oscars Mental Health Services/Claims?
Optum
What can you do on the account and what information can you provide the caller if they are not HIPAA verified?
If they are not verified, you can only take a payment from the caller or share publicly available information (hioscar.com).
Who handles enrollment and termination for ON-Exchange members?
The Market Place
What has a fixed amount cost share and does NOT apply to the deductible?
Copay
If you discussed a ID Card or Welcome Kit, what would be the appropriate ticket tag?
BUGS/Product - Other
What is it called when the members receives a Tax Credit while ON-Exchange?
Subsidy
If a caller calls in about someone other than themselves, what two ways allow us to speak with them?
There is a valid written authorization or HIPAA form on file OR the member gave verbal authorization to the caller for the duration of the phone call.
What escalation would you create for an INN Balance Bill?
Provider Outreach
When does Oscar cover a percentage of the cost of a Claim?
Once the DED (deductible) has been met.
What ticket PRIORITY level would you use if you discussed an Emergency Room or Urgent Care?
Critical
What do we call internal documents sent from the Market Place that update termination, enrollment, and demographic information?
834's