Rx
The phase in which members pay a percentage for all of their medication
Coverage Gap
Where to see the Broker ID
Plan Application Tab / GPS
What JA assists with determining VG categorization?
Compliance OneSource / Grievance Handling
When a member's claims/PA's are processed by a PMG
Delegated
When a member has other insurance coverage (OIC)
COB
The phase in which the member is responsible for 100% of their drug cost
Deductible
Allows the member to enroll into a new plan in the middle of the year
SEP
How long does a member have to submit an appeal?
60 days from the EOB/Paid/Denied date
Rider
When a member is billed by a provider for an amount above their copay/coinsurance
Balance Billing (BB)
The maximum allowed amount of medication dispensed
Quantity Limit
The period of time members are able to enroll into a new plan
AEP - 10/15 - 12/7
Process for which members request a PA on their own behalf
MIOD
What is it called when a plan requires a referral?
Gatekeeper
The standard timeframe for Medical claims processing
30 days
You cannot determine why a Rx claim generated the member copay amount that it did, who can you ask?
Pharmacy Ops
Request to be reinstated into the plan after being termed for NPOP, due to unforeseen circumstances
GCR (Good Cause Reinstatement)
Review that determines if the drug is covered under Rx or Medical
BvD
Where to find complete benefit information?
IBAAG/EOC
This is sent to the member monthly, to provide claim processing information
EOB
What intent would you open to confirm what stage of the drug plan the member is in, and when they will enter the next stage?
Coverage Stage Intent
A request to backdate the plan effective date due to plan error
RPR (Retro Processing Request)
System that displays Part C PA information
ICUE
The date the member's bill prints
Bill cycle date
Member paid OOP for a service and wants their money back, they should file a...
DMR