PLANS
Name of the two government programs that these members are eligible for
What is Medicare and Medicaid
Three places where you can view the benefits for a member's plan
What is EOC or Member Handbook, COE Benefit Summary spreadsheet, Plan websites
OneNote (optional)
Name of the eligibility site to check Medicare eligibility
Marx
Two types of claims processed for these plans
What is PRIMARY and SECONDARY CLAIMS
Process for contacting the member's case manager
What is 1. Teams message 2. Email
What is DEEMING INDICATOR
Request that a member or provider can submit to have a service, item or medication covered by the health plan
Name of the two state sites that you have access to view for Medicaid eligibility
What is CHAMPS and DMAS
Process for sending a claim back to the claims department for review
What is CLAIM REWORK
Name of the main resource used to review workflows and processes for these members.
OneNote (Job aides and COE MS Resources)
Other names that refer to these type of members
What is Duals, Dual-eligible, COE Duals
Optional: MMP - Medicare-Medicaid Plan
One benefit that a member may pay out-of-pocket for and be reimbursed later
Optional (Worldwide medical services)
Name of the two Aetna systems that you will use to view, perform specific actions and document your comments
What is GPS and QNXT
Name of claim messages that give the reason why a claim was paid or denied
Email to use when submitting an expedited appeal or grievance
What is COEGandA@aetna.com
The four states for the HIDE/ FIDE plans that you will handle.
What are IL FIDE, MI HIDE, NJ FIDE, VA FIDE
Name one benefit that uses a vendor to provide services to the member.
What is transportation benefit, hearing benefit, dental benefit, or vision benefit
Name of the site to check if a CPT (procedure) code requires authorization or not
What is PROPAT
Actions to take whenever a member receives a bill from a provider
What is
1. Locate the claim
2. Call the provider
3. Review OneNote resource for appropriate action to take
Main resource to use when you need assistance on your call
Benefit where member may qualify to receive additional money on a card IF they have a chronic condition
What is SSBCI (Special Supplemental Benefits for the Chronically Ill)
Site for performing test claims to get an estimated Rx cost, viewing Rx EOB statements, viewing paid or denied Rx claims, viewing LIS level
What is COS (Client Online Services)
or CCA (Client Care Access)
Department for providers to speak to about claims status
Microsoft Teams tag names to use when requesting assistance for escalated calls and crisis calls
What is @escalated call
What is @crisis call