Enroll&Eligibility
Which member termination codes are eligible for the 31 day grace period in the event of divorce?
DIV
informal representative
members may have to file their own claims when using a ?
non participating provider
if a member has appealed their pre-service urgent care claim and wants to know when they can expect our decision, what would you say?
within 72 hours
can a member receive a medical service from an immediate family member? can it be covered by the plan??
no, it will not be covered by the plan
if the member and spouse are enrolled into a self plus one policy & want to add their adopted child, what needs to occur for dependent to be added?
policy holder must be referred back to HR department
where do you look to verify if you can provide information to a spouse calling about a diagnosis on a claim and theres no authorization on file?
HIPPA verification and disclosure guide
PPO providers are required to...?
file all calims for members
a member wants to know how long they have to request a reconsideration of a pre service non urgent claim. how would you respond?
within 6 months of the decision
the plan does cover extra charges for afterhours care if...?
Never, the plan never covers extra fees charged for afterhours care
how do you access the 2809 and 2810 forms?
opm.gov -> insurance->federal employees and annuitants ->enrollment->enrollment form sf2809
when a dependent is under the age of 18, can a parent that is not listed on the policy call to obtain info about the dependent ?
yes
when can a basic option member use a preferred or non preferred provider and still receive benefits?
when they are outside of the US
member wants to know how to request a review of a previous claim decision, what would you tell them?
they must submit the request in writing
which item would be an exclusion on a claim for an inpatient hospital stay?
medications given during stay
an in room pay per view video rental
food served to the patient during their stay?
how many days do you have to notify your employers HR department for when the dependent becomes 26 years of age?
You have 60 days from the 26th birthday to notify your Human Resources Office your child turned 26.
in addition to the member name, which two pieces of PHI can be accepted to verify a requesters authority?
member ID and DOB
out of pocket costs are generally less when using a ..?
PPO - Preferred Provider
member wants to know how many hours before they will receive a decision regarding the extension they recently requested for an ongoing course of treatment for an urgent claim
within 24 hours
where can you direct a member when asking about discount programs?
case management
using the fehp handbook, what is the enrollment effective date when your employing office accepts a late open season enrollment?
An accepted belated FEHB Open Season enrollment is effective retroactive to the first day of the first pay period which begins on or after January 1.
which type of Rep stands in the shoes of the member?
personal rep
elevance health is allowed to release member medical information and claims to who??
any treating physician or dispensing pharmacies
member calls and wants to know which type of pre-service claim approval is required for an inpatient hospital admission. what do they need?
member wants to process a claim for massage chair for back pain, how would you respond?
explain furniture is an exclusion and will not be covered.