Benefits
Claims
Pharmacy
Membership Accounting
FUSE
Compliance
100
In CSI, going here will give you more information about specific benefits
What are Knowledge Topics
100
This is not a bill. Members confuse this with that.
What is an EOB
100
This is the PBM (Pharmacy Benefit Manager) for IFP plans.
What is Express scripts
100
The name of the system you can access the members premium
What is IKA/HIX
100
This is what you do to assist the member with their question.
What is Add task
100
You need this many pieces of information to authenticate the member
What is three
200
Wheelchairs, for example, will require this before the provider submits the claim
What is an Authorization
200
The member says "I got a bill for a $20 copay for my office visit and that is incorrect", you should verify this first.
What are Benefits
200
This is the list of covered drugs
What is Formulary
200
This is the acronym for the subsidy that helps members with paying their premium
What is APTC (Advanced Premium Tax Credit)
200
Where you are going to document during phone calls
What is FUSE Pulse Notes
200
ID number, date of birth and this can be included as the three pieces needed to authenticate the member
What is address
300
This is another name for a member contract
What is an SBC (Summary of Benefits/Coverage)
300
When it comes to claims processing, this is important for who pays first
What is COB (Coordination of Benefits)
300
These are costly or injectable drugs
What are Specialty
300
This is the grace period for members without a subsidy, to pay their premium
What is 31 days
300
The name of the training environment
What is FUSE Stage
300
This is filled out by the member if they wish to allow someone to discuss their PHI
What is Authorized Statement of Representative (AOR) form
400
This must be met before insurance will kick in with cost sharing
What is deductible
400
If the member paid up front for their medical services, this is what is done to pay the member
What is Direct Member Reimbursement
400
This can be done for a review if the member wants a non covered drug
What is a Coverage Determination
400
We accept the following card types: VISA, MasterCard, Discover, and American Express
What is Pay by Phone
400
OH NO! FUSE is down. Use these to track your calls.
What is a Crash Sheet
400
This is only good for the specific phone call
What is verbal authorization
500
The EOC category for acupuncture
what is Exclusions (Services not covered)
500
You would create this if the member received a bill but you cannot find the claim on file
What is a PFU (Provider Follow Up)
500
This is what MTM stands for
What is Medication Therapy Management
500
General billing information, such as the current balance, can be given to this but only if they are on the account
What is a Spouse
500
You are looking for a known issue in FUSE. It is located here
What is the FUSE Knowledge Tool
500
The member is deceased and someone calls in to discuss their health information. We need to have this type of document
What is Executor of Estate
600
A brick and mortar building where outpatient services can be done at
What is an Ambulatory Surgical Center
600
This would be offered if the claim processed correctly, but the member disagrees
What is an Appeal
600
This is the BIN# and PCN# for IFP
600
The member wants to change how they pay their premium and this is the name of the task you will choose
What is Change Payment Method Task
600
If you save for research, this is the ID of your piece in your workbasket
What is an S-Case
600
This type of POA is NOT eligible to receive a members PHI
What is a Healthcare Power of Attorney