Plan Design
Part D
C&G
Enrollment
Documentation Codes
100
What is the PCP copay on the HMO with RX plan in WPA/OH?
What is $5
100
How many tiers are on the UPMC for Life Formulary?
What is 5
100
A member has how long to file an appeal on a denied service?
What is 60 days
100
The first day a plan can accept an application during open enrollment is
What is October 15
100
This category code is used to document providers
What is PVA
200
This is the term used when a benefit is based on a percentage of the Medicare allowed amount
What is Coinsurance
200
Tier 4 Medications on UPMC for Life apply what cost share?
What is 33% Coinsurance
200
How long does the plan have to make a decision on a grievance?
What is 30 days
200
When an application is not signed, what action does the plan take?
What is Attempt a phone call for confirmation of the person's intention to enroll
200
When discussing premium billing the category code we use is?
What is IVB
300
This is required before any inpatient hospital stay
What is Prior Authorization
300
This is the process of clinical criteria being needed before a medication is covered
What is Prior Authorization/Coverage Determination
300
This is the timeframe for an expedited appeal of a denied organization deterination
What is 72 hours
300
How long does a member have to cancel a pending enrollment request?
What is until the effective date of the plan
300
This activity code is considered the generic code for benefit plan design
What is BNA250
400
What is the combined in/out of network out of pocket max for the PPO High Deductible plan in WPA/OH?
What is $10,000
400
How long does the health plan have to process an expedited coverage determination?
What is 24 hours
400
When the plan makes an adverse decision on a reconsideration, who is the case forwarded to?
What is IRE
400
Members can not enroll into a different MA plan outside of they're current organization if they have this chronic condition
What is ESRD
400
We use this code for coverage determinations
What is RXF800
500
How many months is the rental period for a hospital bed?
What is 13 months
500
This is the term for when the plan decides to cover a medication that they do not usually cover
What is Non-formulary Exception
500
How long does the plan have to decide on a good cause reinstatement?
What is 8-10 business days
500
This TRC code is the code those who are making an enrollment change from an employer or union group plan
What is TRC127
500
This is the activity code used for Good Cause Reinstatement requests
What is GCA055
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