M&R claims
Which intent do you use to view Medical Claims
Review Medical Claim History intent
Which Job aid is used when helping a member with LIS questions?
Low Income Subsidy (LIS) - Index
Will prescription medications purchased outside of the United States (including in Canada or on any cruise ship) be covered by medicare Part D?
No
Which Job aid will you use to help members with Website Issues?
Medicare Plan Websites- index
Susie Claxton called because she received a letter saying she could be penalized for not having Part D coverage. Which intent would you use to assist the member?
Manage LEP
What is the primary tool (job aid) for interpreting claim status?
Claims Codes and ICES - Index
Who can the member be transferred to, or call, to apply for LIS?
Social Security
When does the Coverage gap end?
when your yearly out-of-pocket drug costs reach the True Out-of-pocket (TrOOP) limit for the benefit year, OR the new plan year starts
Which Maestro Intent will be used to help members with website issues?
Website Issues
Which job aid would you use to explain the LEP (Late Enrollment Penalty) to a member?
LEP Index
What tab do you click on to view a breakdown of the copay/co-insurance for each procedure speficically?
Service Line Detail
What does BAE stand for in terms of LIS?
Best Available Evidence
The __________ _____ is the period prior to plan coverage beginning. During this stage of coverage, the member is responsible for 100% of their drug costs for tiers that this certain stage applies to.
The Deductible Stage
What page can a member view their ID card, see their recent claims, and a quick link to benefits overview?
Dashboard
How long does it take to process a LEP Attestation by phone or by mail?
14 calendar days
What tool will assist you with determining liability and next steps for both COSMOS & NICE claims with denial or adjustment codes?
Claim Decoder Macro
LIS discrepancies occur when LIS information in ______ and _______ do not match.
MARx & Maestro
During this stage the member pays the applicable copay or coinsurance for covered medications
The Initial coverage stage
Which job aid will be used to help a member register for their member portal?
HSID Index- Member Website and UHC Mobile App
Can a LEP be assessed from a previous plan?
yes
VBC plans in california can have a special arrangement where members claims could be paid by the PMG or the hospital depending on the circumstance. What is this arrangement called?
Split Capitation
LIS Disputes occur when ___ ______ disagrees with the LIS level in MARx
the Member
What are the four stages of prescription coverage?
Deductible, Initial Coverage, Coverage Gap, Catastrophic Coverage.
Who requires health plans to report gaps in Part D coverage?
The Center for Medicare and Medicaid Services / CMS