Enrollment/Eligibility
Plan that requires a member to live in an institution for at least 90 days.
What is ISNP (Institutional Special Needs Plan)
Name of the main menu to access different sections of the member's account.
What is Menu Navigation
Section in GPS where you can view the benefits covered on a member's plan.
What is the BENEFITS section
Section in GPS where you can view the services that a provider billed to Aetna and how Aetna processed and paid for those services
What is the CLAIMS section
Three ways that a member can file a standard appeal
In writing by mail
Fax
Online
Form that must be completed to verify that a CSNP plan member has a qualifying chronic condition.
What is VCC (Verification of Chronic Condition) form
Name of the number generated whenever you open up the member's account
What is a CASE NUMBER
The three cost share types that a CSNP plan member could pay on their plan
What is Deductible, Coinsurance, Copays
The amount on a claim that advises what the member has to pay for the services they received from a provider
What is MEMBER RESPONSIBILITY
Systems where prior authorization requests can be viewed
What is Medcompass and Evicore/Carecore
Both CSNP and ISNP members must be eligibile for this federal government health insurance program.
What is Medicare
What is CREATE A SERVICE REQUEST
The book that is sent to members to explain their benefits and covered services and advises how much a member has to pay out-of-pocket.
What is the EOC (Evidence of Coverage)
Process for sending a claim back to the claims department for review
What is CLAIM REWORK
Service Request Reason to choose when submitting a grievance for a member
What is Complaint/Appeal/Authorization
Form that must be completed and returned along with the enrollment application for a CSNP plan to advise of a chronic condition.
What is PQAT (Pre-enrollment Qualification Assessment Tool) form
Name of the resources in GPS that will advise about workflows and processes to perform on a member's account
What is KNOWLEDGE ARTICLES
What is the name of the section in GPS that allows you to see the MOOP (max out-of-pocket) balance?
What is Accumulators
Name of the statement sent to members to show what claims were received and processed by Aetna
What is EOB (Explanation of Benefits) STATEMENT
Name of the process for submitting a request to Aetna to review a denied medical service, authorization, or medication PRIOR to receiving the service
What is EXPEDITED APPEAL
The system that allows you to see the name of the institution that an ISNP member currently lives in.
What is Market Prominence
Four places where you can view the benefits for a member's plan
What is GPS (Benefits section), EOC, Stars Tool, Aetna website (Aetna.com/medicare)
Section on a claim that allows you to see claim details such as procedure (CPT) codes, Dx (diagnoses) codes, and benefit label (office visit, PCP, specialist) info
What is CLAIM LINES
Name of the site to check if a CPT (procedure) code requires authorization or not
What is the NPL (National Participating Provider Preceertification List)