Networks & Eligibility
The set dollar amount the member must pay for their medical care before Health Net will begin to pay for services
Deductible
The call as a whole is referred to as a(n) ?
Interaction
An amount the member must reach before Health Net pays 100% of covered expenses for the remainder of the year
OOPM/ Out of Pocket
For California Commercial PPO member, Health Net is responsible for processing standard appeals within
15 Business Days
Source containing Informational documents, such as Quick Reference Guides, processes and procedures, Hot Topics, and other references and training materials
KB
Member responsible for billed charges exceeding this amount
MAA
The PPG establishes a capitated incentive arrangement with a primary hospital.
Dual Risk
Amount member must pay out of pocket before benefits begin
Deductible
Expedited appeals are handled within how many hours?
72 Hrs
Representatives use this Health Net/Centene desktop application to document interactions with all of our callers and to send service objects to various departments as needed.
OMNI
What is the name of the plan that replaces both Part A and Part B Medicare, and is offered by private insurance companies approved by Medicare?
Medicare Advantage
This document should always be reviewed anytime there are details needed regarding the member’s benefits, services, and cross-accumulation of deductibles and out of pocket maximums
EOC/ Evidence of Coverage
All CPT codes are composed of _______________ digits and used for outpatient and professional services
5 Digits
It is a verbal or written request by the caller to overturn a denial, modification, or delay of a determination made by Health Net, delegated vendor, medical group, or the member’s provider.
Appeal
An application that allows a representative to send faxes to our callers
FaxCom
What Part of Medicare covers prescription drug coverage?
Part D
In order to look up outpatient professional procedure codes, utilize the __________ reference book:
CPT Plus
What disclaimer must be read when quoting preventive care benefits?
Preventive Disclaimer
What is the KB article number for Appeals and Grievance?
KB 102017
Legacy Health Net mainframe program used to store member and provider information. This system uses prompts, such as MMINQ, to navigate data.
ABS/BLUEZONE
What is the KB number for the California Resource Listing?
KB 95473
If the risk type shows "Dual Risk" and the mark or letter is at the third column, who will be at risk?
Capitated Hospital
When a call back is scheduled, CSRs only have to make____attempt/s to reach the caller prior to closing out their intent.
Using MACESS, where to route Expedited Appeals and Grievance?
*Member A&G All
An application used to send and receive internal email communications
Outlook