QUOTING BENEFITS 1
What is the first step in quoting Transplant benefit?
CHECK THE COB
What should we search in GPS for benefit: Infertility and the POS is in a facility
Outpatient Diagnostic X-ray and Laboratory
It's a tab where you can see if the deductible & OOP is met
ACCUMULATORS
Give at least 3 examples of Orthotics
Ankle-foot orthotic, Back brace, Knee brace, Ankle brace, Wrist brace
What are the 2 types of hospice benefits?
Enhanced and Non-enhanced
What should we quote for Home-based Therapy benefit if it's old style?
HOME HEALTH CARE
What are the 3 mandatory services you need to quote when quoting maternity?
Maternity
Pre-natal
Delivery
It's a tab where you can check if aetna is the primary or secondary plan of the member
COB TAB
Whare are included on the Expanded Benefits for ACCP? Give at least 1 or 2
Curative Care, Respite Care and Bereavement Care
Give atleast 2 examples of high-tech radiology procedure services.
MRI/MRAs, CT scans, PET scans, Nuclear Imaging
What should we quote for Home Health Care benefit if there's no result after your search "Home" or "Home Health Care?
SPECIALIST
What are the steps in quoting foot orthotics?
*with result- advised the caller that we only cover foot orthotics if it's related to diabetics
*If patient is diabetic , quote under DME
*if not diabetic- not covered
*no result- no covered
The lower section of this box identifies high level information about the case like how the case originated, the callers name and what the caller is calling about
CASE DETAILS
What are the "3 steps they may" for Contraceptives
Be prescribed
Be over the counter
Treat medical conditions
Provide the 3 components for ACCP
Case management
Information and tools
Expanded benefits
What should we quote for Home-based Therapy benefit if it's new style?
SHORT TERM REHABILITATION
If the caller ask for Benefit for Oral Surgery under Medical Plan and the POS is Office. What would be the coverage?
>Medical Plan- Oral surgery Center of Excellence
*POS Office- Transfer (Oral surgery Center of Excellence)
The screen for the selected accumulator opens a new tab in the center panel, where you can view all claims tied to that accumulator—including the date of service, provider name, billed amount, the portion applied to the accumulator, and the remaining balance.
VIEW ASSOCIATED TRANSACTIONS
What are the services included in a Sick visit? Provide 3
Consultation
Diagnoses
Xray & labs
Minor surgery
what are included in Preventive Care office Visits?
physical exams
immunizations
screening
What are the steps when quoting enteral parental formula?
Ask how it will be administered
Oral – quote nutritional supplement, if no result check PSPP for restriction or coverage, if no result, means no coverage
Enteral & parenteral - quote under prosthetics, if no result quote DME
When quoting physicians/ additional provider, how do you quote if its under OUTPATIENT
Outpatient surg
if there is outline for surgeon, co surgeon, co-surgeon/anesthesiologist prov the quote.
Determining if the Validated Provider is an IOQ
Provider Details under Flags
It administers an authorization for specific high-tech radiology procedure services. We contract with an outsider vendor like eviCore Healthcare (formally MedSolutions Inc. and CareCore National for procedures.
Enhanced Clinical Review Program (ECRP)
Give at least 2 examples of situations when Aena doesn't pay globally for maternity.
- The member's coverage terminated. We only allow the services rendered while the member had active coverage.
- The member changed care providers during pregnancy.
- The member changed insurance carriers during the pregnancy.