Terms
EPO spelled out
What is Exclusive Provider Organization?
Plan names have to contain these, in order to have OON benefits
What is PPO, HMO POS,RPPO?
Dental plans can be structured to include dental in these 3 ways
What are MSB, OSB or Combo?
Resource guide used to read full descriptions of member benefits.
What is the EOC?
Always use this to search for available providers for our members
What are the Aetna/Liberty websites?
A provider who has advanced education and training in one clinical area of practice.
What is a Specialist?
These plans cover all ADA codes except for a select number of cosmetic, codes medical in Nature, and administrative codes. (These plans will switch names in 2025.)
What are Total/Choice Plans?
Combo plans come with ______ services embedded and the option to add ______ services for an additional premium
What are Preventative and Comprehensive
EPDB (rumba)
All contracted providers must participate in this, in order to be considered INN
What is the Aetna Dental PPO Network?
ADA spelled out
What is American Dental Association?
These plans do not require our members to see INN providers regardless the plan name.
What is DMR Plans?
When can OSB be added?
What is during AEP (any election period), or within 30 days of effective date?
The system that shows year over year benefits where we can use the search bar to locate benefit
What is the SCP Stars Central Portal?
It is not enough to look up a provider name to ensure you are properly assisting the member, what else must be verified?
What is the Servicing location?
6 names of the types of Scheduled Benefit Plans options in 2025.
What is Preventive, Deluxe, Broad, Choice, Essential, SNP Enhanced?
These plans can cover different levels of comprehensive services from preventative only to Deluxe.
Scheduled Benefits EPO/PPO plans
True or False: The member can stop paying their OSB premium to end Dental coverage at anytime.
True, member will have a 90 day grace period.
To see where the member stands towards their annual maximums and frequencies.
Why do to go to GPS accumulators?
What are the 2 provider flags that we search for?
DENMEDCR and PRIVCON
Major Dental adds this service to basic comprehensive dental
Crowns
True or False. Scheduled benefit plans are the only plans with both frequency limits and benefit maximums
What determines the type of dental coverage the member receives?
The plan they choose and the service area
To speak with and document provider calls you must do this.
What is a provider search?
This screen will tell you what net ids each provider participates in
Provider Summary Screen in EPDB