To regain or recover funds sent to a member or provider?
Recoupment
100
For New York State of Health (NYSoH) metal plans, a tax credit is applied to a member's:
PREMIUM
100
- See doctor through computer, mobile device or phone
- Telehealth
100
Who submits claims?
Participating and
Non-participating professionals
100
What are the 2017 EMBLEMHEALTH INDIVIDUAL PLANS (FOR INDIVIDUALS AND FAMILIES) Available Off the NY State of Health’s Individual Marketplace?
Select Care Platinum D HMO
Select Care Silver D HMO
Select Care Bronze D HMO
Select Care Basic
Select Care Silver Value HMO
Select Care Bronze Value HMO
200
Dr. Adam's claim has a status code of 11in E-SAWS. What will you communicate to Dr. Adams?
The claim is paid.
200
Your co-worker Rhea, is not sure who qualifies for the Silver 2 & 3 plans that remained active in 2017. You advise her to qualify, someone must be:
65 and older and do not qualify for Medicare
200
What small groups covered the following? Pcp 2 free sick visit, 0 before deductible, 0 generic drug, 0 lab service, 0 preventive care and 0 telehealth.
- Small Group Plan Bronze Value S
200
Give the three professional providers, and differentiate it from each other.
In-office, These are any health services provided in the doctor’s office. / Out-patient hospital- specialist at a centralized location such as medical center. / In-patient-when a specialist renders a service to a patient in a facility.
200
What are the 2017 EMBLEMHEALTH SMALL GROUP PLANS (FOR GROUPS WITH UP TO 100 ELIGIBLE EMPLOYEES)
Available On the NY State of Health’s Small Business Marketplace (New York’s SHOP)?
Select Care Platinum S
Select Care Gold S
Select Care Silver S
Select Care Bronze S
300
While researching a claim, you see the ClaimsXten rule acronym of BASE-Co_De_QNTY. What will you communicate to the provider?
Claim exceeds the maximum allowed units.
300
Jenna heard that in 2017 a service will now be incorporated into her Select Care Gold plan and she will no longer have a separate bill. Which service is Jenna refering to?
Pediatric Dental.
300
- Process in Enrolling in emblemhealth’s direct pay plans
Contact Direct Marketing for information regarding EmblemHealth’s plans. / Able to enroll via EmblemHealth’s website. / Direct Marketing representatives can assist with the enrollment process / Premium payment will be due via Webpay
300
Enumerate the four inpatient providers.
Outpatient care-service
Ambulatory Care Facility
Psychotherapy
Physical Therapy
300
What is Premium Rewards?
Groups have a unique opportunity to earn back a percentage of their premium dollars. At the end of the year, if their actual claims costs are lower than
expected, EmblemHealth will credit their premium payment for the following year when they renew with us. By staying year after year, the business will share in a larger
percentage of the savings. If claims costs are higher than expected in a given year, no deficit payment will be due.
400
If a claim was reviewed by iHealth, the iHealth flag will display a Y hyperlink.
No.
400
Rey is inquiring about a new 2017 plan that offers 3 free preventive visits. $0 copay for generic drugs, lab and telemedicine. He is relatively healthy, which plan would you offer Rey?
Select Care Silver Value
400
Consumers can contact Direct Marketing for information regarding EmblemHealth’s plans.
- Enrolling in emblemhealth’s direct pay plans
400
What is the payor I.D for HIP plan?
55247
400
What is Network Access for Self-Administered Plans
Self-administered groups get cost-effective access to practitioners through leasing arrangements. Self-administered businesses can choose medical.
500
Which QCare Subsystem will need to be accessed to see when recoupment began and the reason for the recoupment.
- Provider Accounting
500
Which is the correct premium payment amount for an Essential Plan 2 Plus member residing in the Suffolk?
$31.97
500
The ACA and New York State’s “Age 29” law offer ways for adult children to continue to be covered by their parent’s health plan.
- Riders: adult child coverage.
500
What is Extended 837 Project?
o eliminate paper claims by automating the COB process and accepting commercial COB claims electronically from providers
500
What is Funding Options?
With certain plans, groups control expenses and lock in rates. Full-service funding choices include prospective, retrospective, minimum or deferred premiums.