NYS Mandates
Delegated Entities
Grievance and Appeals
Member Billing
Pre Auth and referral
100
The ambulance Mandate also covers non-emergent transportation. True or False
CME_010009 False. Pre-hospital emergency medical services refer to the prompt evaluation and treatment of an emergency medical condition and/or non-airborne transportation to the hospital.
100
What is this type of HMO contracts with individual physicians to care for members in their own private offices and are free to contract with more than one plan.
IPA which stands for Independent Practice Association or Individual Physician’s Association CME_013145
100
What do you call a written request by a provider to reverse an initial adverse determination for an admission, extension of stay, or other health care service that was received?
clinical appeal CME_004758
100
Can the member’s due date be changed?
No cmore 012005
100
A pregnant member needs a referral to see an OBGYN because an OBGYN is a specialist. TRUE or FALSE.
FALSE CME_001117
200
A member is covered for either E0603 and E0602. True or False.
CME_ 000599 False. A member is covered for either E0603 OR E0602. The member will not be covered for both electric and manual breast pumps.
200
What are the CAIPA medical center number?
14PA and 14PY CME_013145
200
What must a member receive in order to file an appeal?
denial letter CME_004758
200
If the caller is the parent or guardian of a Child Health Plus member, how long should they expect full processing of the application for direct debit and the first debit to their bank account?
sixty (60) to ninety (90) days from the time the application is received cmore -013610
200
A PCP may refer members with chronic, disabling and/or degenerative conditions to a specialist for a set number of visits within a specified time period.
TRUE CME_025036
300
A _________ bill is not a bill received for health care services when a par physician is available and the member has elected to obtain services from a non-par physician.
CME_153089 SURPRISE
300
Member is under the med ctr 14MM, the member needs meter and testing supplies. Who should the member contact to get these?
CME_154885 Meters and testing supplies are obtained through Abbott. www.AbbottDiabetesCare.com 1-888-522-5226
300
What do you call an expression of dissatisfaction that does not involve changing a previous plan decision?
verbal complaint CME_004758
300
How long do all Direct Pay bills go out?
two weeks before the 1st of the month cmore-012005
300
What is the maximum number of units and the visit duration of Radiation Therapy authorization?
40 visits and 180 days CME_001117
400
Can Groups Opt Out of the Federal Requirements of the Women’s Preventive Services Provision
CME_023478 Generally, no. However, certain qualified religious entities may be exempt from covering contraceptive services.
400
Who do members contact for referrals and prior approval information when a member selects a PCP under 14HY?
HCP CME_171940 In December of 2016, approximately 1,200 PCPs were advised that as of 2/1/17, they must contact Health Care Partners (HCP) for referrals and authorizations.
400
What can be requested by a contracted facility when a member is admitted into the facility and there is no prior approval on the system resulting in a denied claim?
retrospective utilization review CME_004758
400
How long should we receive the initial premium for a new members?
within 10 days of the month of coverage cmore-001651
400
This is a clinical description of medical services recommended by a referring physician.
SCRIPTS CME_025036
500
A HIP member calls and said that her doctor prescribed her Sustacal to enhance her nutrition because she amino acid deficiency. She wants to check if this is covered. What will you advise the member.
CME_010041 if GHI is not the prescription drug carrier for a group, it is not obligated to  provide enteral formula coverage
500
Who processes claims for mental health if the member is under ACPNY.
Emblemhealth processes all claims. CME_154885
500
What do you call of a request for information from a member or provider that does not fall under the complaint, appeal, retrospective utilization review or grievance process?
Correspondence CME_004758
500
Until what time can members can hand-carry their payment into the Walk-In Unit?
no later than 4:55pm CME_012005
500
Why does the non-par provider contact EmblemHealth to establish a pre-cert notification if a member’s benefits include the entitlement of in-network and out-of-network services?
This is to ensure that the member does not receive a financial penalty for the service covered in accordance to the benefit plan. CME_025036
M
e
n
u