Eligibility
What kind of grace period do policies without APTC have?
31 day grace period
Claim summary or adj. summary
Who is the CS supervisor?
Ana Karen
True or False: A member must meet their deductible before copay applies?
False
What are 3 things you may find in the admin portal besides the demographic information?
ID cards, Notes, Letters sent to the member, member portal shadowing, network, etc
If a member is in GP2 and has paid the full balance can we release a medical hold?
No we are only able to remove RX holds when the payment has been paid in full and by card.
If a claim is showing RTC what does that mean?
Ready to close
What are the 2 types of claim forms?
UB-04 and HCFA 1500
4th quarter carry over does not apply to what kind of plans?
high deductible plan health plan (HDHP)
What system is used to verify if a provider is in network/out of network and what are the 2 ways to access that system?
Internal provider search
Admin portal and Callnotes
If today is 02/26/2026 and their ptd is showing 01/31/2026 what would their GP indicator show?
GP1
What does it mean when we send out a zero check to a provider when we have paid on a claim?
That we have done a recoupment.
Finance
What does IFP stand for?
Individual Family Plan
In what system can you find medical pharmacy drug PA's?
Prime
During each stage of grace, the member receives notification of the outstanding payment, What are the four communications sent to the member?
Text messages (mPulse)
Warning letters
Invoices
Termination letter
32
What are all our member id's start with and who do they belong to?
AM - Group
44- Group
000- Individual
AS- Individual
What are 3 kinds of qualifying life events for a sep window?
What information would you give to a provider calling in for prior authorization status and what system are you using?
Essette
Auth #, service date range, approval/denial
Today's date is 02/10/2026 and the member's PTD is 11/30/2025 by what date must the member pay to avoid termination? (Mbr with APTC)
The member must pay by 02/28/2026 to avoid termination.
What are the 8 things you will provide when a provider is calling in for claim status?
Claim #
Recd date
Allowed amount
Amount Paid
Tpr
Processed date
payment method
payment amount
What does our PPO, HMO, EPO plans start with?
PPO- 4
HMO- 11
EPO-1
Who would be able to balance bill a member?
A out of network provider
In what system can you check how many visits a member have used for physical therapy?
Meditrac