Eligibility and Enrollment
What is a premium?
a. The amount you pay for insurance coverage each month.
b. The total cost of all medical services you receive.
c. The amount you pay when you visit a doctor.
d. The money you receive back from your insurance company
What are the names of Johns Dogs?
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What is a pre-service appeal?
a. A request to change a doctor before receiving medical care.
b. A process to challenge a decision made about coverage before a medical service is given.
c. A way to ask for a refund after receiving medical services.
d. A form to update your personal information with the insurance company
How will you do an update/change address?
a. Follow the guided workflow in GPS.
b. Send the member to the Telesales Team.
c. We don’t care of address changes.
d. Send the member to the Enrollment Team
What is a late enrollment penalty (LEP), and how can it affect the plan’s premium?
a. It is a charge applied each month if a member went 63 days or more without creditable
coverage.
b. It decreases your premium if you enroll late.
c. It has no impact on your premium at all.
d. It only applies to people who are over 65 years old.
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When a member submits for a claim reimbursement, what system can we check to confirm delivery?
a. Wiki Tool
b. Market Prominence
c. STARs Central Portal
d. Electronic Correspondence Handling System (ECHS)
What is a post-service appeal?
a. A process to challenge a decision made about coverage after treatment has been
provided.
b. A request to refund medical services that were paid up front.
c. A process explained to leave the plan.
d. A way to get non-covered services covered
What happens if a member moves out of their service area?
a. They can keep their current plan without any changes.
b. They will qualify for a Special Election Period (SEP) to choose a new plan.
c. They must wait until the next enrollment period to make changes
d. They will automatically be assigned a new plan
What are some important things to know about Social Security premium withholding (SSPWH)?
Select up to 2
a. The request can be submitted by Member Services.
b. The member contacts Medicare to set it up.
c. It can take up to three months for premiums to be withdrawn from a member's check.
d. The request is sent thru PNC
Which SMEs favorite movie is Rush Hour?
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What is a message code on a claim used for?
a. To indicate what type of Dr performed the service.
b. To indicate the type of medical service provided.
c. To show much the member needs to pay.
d. To communicate any issues or reasons for claim denial.
What system houses Medicare appeals, grievances, and case tracking messages (CTMs)?
a. Wiki Tool
b. GPS
c. MedHok
d. Market Prominence
When would you do a temporary address change?
a. When a member is moving to a new home permanently.
b. When a member is staying at a different address for a short time, like during a vacation
or while visiting family.
c. When a member wants to change their address for a different insurance plan.
d. When a member has not moved but wants to update their contact information
What does enrollment cancellation mean?
a. It is when a member decides to stop their enrollment in a plan prior to the plan’s
effective date.
b. It is when a member adds a new family member to their insurance.
c. It is when a member updates their personal information in the system.
d. It is when a member chooses to add OSB coverage.
Why might a claim be denied due to coordination of benefits (COB)?
a. The member didn't provide their insurance information.
b. The claim was submitted too late.
c. The member has more than one insurance plan, and the claim needs to be processed by
the primary insurance first.
d. The provider is not in the network
When would we offer a pre-service expedited appeal?
a. When a member has a procedure scheduled next week and we denied the authorization
request.
b. When a member wants to change their doctor before their next appointment.
c. When a member wants to file a complaint about their insurance plan.
d. When a member is asking for a refund after receiving treatment
What is the difference between referrals and precertifications?
a. Referrals and precertifications mean the same thing and can be used interchangeably.
b. Referrals are only for children, while precertifications are for adults.
c. Referrals are for emergency visits, and precertifications are for regular check-ups.
d. Referrals are needed to see a specialist, while precertifications are required for certain medical procedures or tests.
When might you need to use EPDB?
a. When you want to enroll a new member in a health plan.
b. When you need to check the status of a claim or payment.
c. When you may need to verify a doctor’s network status outside of GPS.
d. When you need to look up information about a member's benefits or eligibility.
Besides GPS, what system can we use to get more details about a claim?
a. MARx
b. EPDB
c. HealthRules Payor (HRP)
d. STARs Central Portal (SCP)
What do we need to confirm if a provider is participating in the member’s network when using
EPDB? Select 2
a. Network ID
b. Gender
c. Phone Number
d. Product (MEHMO or MEPPO