Category 1
Felicia called in to ask for her husband the benefits for surgical treatment of impotence. Under what benefit will it be covered?
a. Rehabilitation Services - Outpatient Speech Therapy
b. Congenital Heart Disease Surgeries
c. Surgery Outpatient
d. Hospital - Inpatient Stay
c. Surgery Outpatient
Joshua called in to check his claim details and asked about the definition of deductible, copay and coinsurance. As an advocate, which should be the correct explanation to the member?
a. Hi, Joshua! Upon checking here, your claims was processed correctly and the deductible is the amount that you could owe during a coverage period for health care services your plan covers and needs to be fully met before the coinsurance will kick in. On the other hand, Coinsurance is the insured individial's share of the costs of a covered expense that is expressed as a percentage. Copay is a fixed amount that you need to pay for a covered service.
b. Hi Joshua! Upon checking here, your claims was processed correctly and the deductible is the fixed amount you need to pay for a covered service. Coinsurance is the amount the member must pay for the health insurance or plan and, Copay includes deductible and coinsurance that will have the services be covered at 100% once it is satisfied.
c. Hi Joshua! Upon checking here, your claims was processed correctly and the deductible is the sum of copay and coinsurance and once it is satisfied, 100% of all the health services will be covered. Copay is the fixed amount you need to pay for a health service and coinsurance is the amount the member must pay through his employer for the plan
a. Hi, Joshua! Upon checking here, your claims was processed correctly and the deductible is the amount that you could owe during a coverage period for health care services your plan covers and needs to be fully met before the coinsurance will kick in. On the other hand, Coinsurance is the insured individial's share of the costs of a covered expense that is expressed as a percentage. Copay is a fixed amount that you need to pay for a covered service.
Based on the Benefit Category Tool, what are the benefits to consider when a member is asking about Gender Reassignment Surgery? You have already determmined that the service is covered by the plan.
a. Physician Fees for Surgical and Medical Services
Hospital - Inpatient Services
b. Physician Fees for Surgical and Medical Services
Anesthesia Services
c. Anesthesia Services
Hospital - Inpatient Services
d. Physician Fees for Surgical and Medical Services
Anesthesia Services
Hospital - Inpatient Services
d.Physician Fees for Surgical and Medical Services
Anesthesia Services
Hospital - Inpatient Services
Samantha is asking about her PCP that was randomly assigned to her. She is asking if why it happened that there is a random assignment of PCP where she did not opt to have that PCP assignment. As you check the ISET, you saw that there is a random PCP, how would you explain it to the member?
a. Samantha, as I can see, you do have a PCP on your plan and the reason why it was randomly assigned is because your plan will be terminated on December 31, 2025 and we should randomly put a PCP on your plan.
b. Samantha, as I can see, you do have a PCP on your plan and the reason why it was randomly assigned is because during open enrollment period, there is no selected PCP that is why the random assignment occured.
c. Samantha, as I can see, you do have a PCP on your plan and the reason why it was randomly assigned is your previous PCP called us to recommend this currently assigned PCP on your plan.
b. Samantha, as I can see, you do have a PCP on your plan and the reason why it was randomly assigned is because during open enrollment period, there is no selected PCP that is why the random assignment occured.
Johnny has a referral for physical therapy under the Standard referral type. He is covered for up to six visits within six months. However, he only uses three visits within the first six months.What happens to James's unused visits?
a. They can be used anytime in the future without a new referral.
b. They expire after six months, and a new referral will need to be submitted.
c. They are automatically transferred to the next six-month period.
d. They can be used by any other family member.
b. They expire after six months, and a new referral will need to be submitted.
Tyrese asked about his plan's original effective date. As an advocate, you should be able to locate it in ISET. Which tab can it be found and which section in ISET?
a. Pharmacy > RxMember
b. Eligibility > Member Details
c. Claims > Search & Detail
d. Benefits > IBAAG
b. Eligibility > Member Details
True or False: Effective June 5, the MyUHC Helpdesk toll-free number 877-844-4999 will be decommissioned and no longer active.
a. True
b. False
a. True
True or False: ADP TotalSource plans are renewing on 6/1/2025. With the renewal, all ADP plans that were on the PRIME platform will be migrated to USP.
a. True
b. False
a. True
Rhys called in to check the provider status of his primary care physician. As a Prime advocate, you were able to provide the needed information to Rhys, what else should you do as part of embracing the gray?
a. Close out the call
b. Make sure that you already provided all the information to Rhys and do a temp check if he still need any help
c. Offer self-service option and ask if Rhys wants you to help him walkthrough the portal to check the provider status
d. Quote the primary care physician benefit
c. Offer self-service option and ask if Rhys wants you to help him walkthrough the portal to check the provider status
What does it mean if the provider have Q&E rating or two blue hearts in Rally?
a. Quality and Cost Efficiency - It means that the care provider has met guidelines for providing quality and cost-efficient care and standard INN benefit will apply.
b. Quality and Cost Efficiency - It means that the care provider has met guidelines for providing quality care but services are expensive.
c. Quality and Cost Efficiency - It means that the care provider has met guidelines for providing quality and cost-efficient care. They are considered as Tier 1 provider and have best benefit level.
d. Quality and Cost Efficiency - It means that the care provider has met guidelines for cost-efficient care.
c. Quality and Cost Efficiency - It means that the care provider has met guidelines for providing quality and cost-efficient care. They are considered as Tier 1 provider and have best benefit level.