HIPAA
It was created to reduce health care fraud and abuse, and guarantee security and privacy of all consumers.
What is HIPAA? or What is Health Insurance Portability and Accountability Act of 1996?
What is this type of HMO contracts with individual physicians to care for members in their own private offices and are free to contract with more than one plan.
What is IPA? or What is Independent Practice Association or Individual Physician’s Association?
IDs used to search for a member in ESAWS
What are
CIN Number (for Medicaid members)
New Member ID (NMI)
Social Security Number
HIX Number
Does not cover IVF, GIFT, ZIFT, FET or more complex infertility treatments.
What is Infertility Mandate?
A medical condition in which the heart is enlarged. It is more commonly referred to as an enlarged heart
What is Cardiomegaly?
Any information—including demographic information, oral, recorded, or any other medium, that relates to an individual’s health, healthcare services, or a payment for services—that identifies the individual.
What is PHI? or What is Protected Health Information?
Preferred Providers of EmblemHealth, if selected as PCP the member will pay a lower copay for primary care office visits as well as most specialist care.
Who is ACPNY and CMO?
When clicked a screen will pull up where the rider list for that contract as well access a summary document highlighting benefits can be viewed
What is CAT#? or What is spyglass beside CAT#?
Prohibit insurers and HMOs from limiting a woman’s direct access to primary or preventative services or pregnancy related care from a qualified network provider of her choice to less than two examinations per year for most insured groups. Likewise, insurers and HMOs may not limit direct access to follow-up care or treatment that becomes necessary as a result of such examinations or as a result of an acute gynecological condition. |
What is Women’s Preventive Services (WPS) Mandate or Well Woman Mandate?
A medical practitioner qualified to diagnose and treat tumors
What is an Oncologist?
These are identifiable information to verify the identity of a caller prior to releasing member PHI.
What are
Member ID
Caller’s Name (and relationship to member)
Member Name
Member Address
Member Date of Birth (DOB)
The preferred independent laboratory for all laboratory testing, including genetic tests, like BRCA.
Who is Quest Diagnostics?
This detailed information can be displayed as form view or list view which displays as a single line of data. Provides a snapshot of the Member including full name & address, DOB, PCP, etc.
Buttons at the top of the grid are for Request and Reference Options
The spyglasses, when clicked, will provide additional information (if applicable)
Alerts may appear, providing additional information
What is Member Demographics?
Requires HMO’s and indemnity carriers to provide a minimum of 30 inpatient mental health days and 20 outpatient mental health visits and mandates unlimited inpatient, partial hospitalization and outpatient mental health coverage for large group policyholders for treatment of specific Mental Health biologically based diagnoses and Children with Serious Emotional Disturbances (SED). |
What is Timothy's Law? or What is Mental Health Parity Law?
An enhanced form of x-ray technology that is used to measure bone loss.
What is a DEXA Scan? or What is a dual energy X-ray absorptiometry scan?
A HIPAA validation which do not require a second level of validation.
What is information collected by an automated system and viewable by the agent?
Manages the following services for Health Insurance Plan of Greater New York (HIP) EmblemHealth, beginning January 1, 2018
Skilled Nursing Facilities
Inpatient Rehabilitation Facilities
Long Term Acute Care Facilities
Durable Medical Equipment
Home Health Care (except PCA –personal care assistant, CDPAP consumer directed personal assistance program)
Who is Evicore?
Display any alert that has been setup for the member. Alert Types maybe: Domestic Issues; Identity/ Eligibility issues; Mailing Issues; PCP restrictions; or Member Password Verification.
What is Patient Alerts?
Establishes regulations around a dispute resolution process that holds the members harmless for costs associated with non-emergency services, unexpected bills from non-par providers or "surprise bills"
What is Out of Network (OON) Bill?
The administration of antigenic material to stimulate an individual's immune system to develop adaptive immunity to a pathogen.
What is Vaccination?
A member may grant an individual to speak on their behalf even without a HIPAA authorization on file but is only for the duration of the call.
What is verbal authorization?
Used to be known as ValueOptions, administers covered inpatient, outpatient and ambulatory behavioral health services including provider network and care management services such as utilization management and case management.
Who is Beacon Health Options?
Allows the advocate to document inquiries without having to click on the Create SR button and choose a Category and Subcategory. It also allows the advocate to select the Primary and Linked Entities.
What is a Wizard SR?
Covers newborn care, under the mother’s maternity benefit, for the first 48 hours after vaginal delivery and the first 96 hours after cesarean delivery. Allows the member up to 30 days from the baby’s date of birth to enroll the newborn.
What is a Newborn Mandate?
Designed to provide support to the patient and their loved ones during the final phase of life. Focuses on comfort and provides a better quality of life, with the goal to enable patient to have an alert, pain-free life and live each day as fully as possible.
What is Hospice Care?