HIPAA
These pieces of information are required to be verified in ACE before you can help a member.
What are Subscriber ID, First and Last name of caller, DOB?
A person other than the subscriber, such as a spouse or child, who is provided coverage under a subscriber’s plan.
What is a Dependent?
This tab displays Medicare eligibility effective dates.
What is the Medicare Tab?
The two systems you use to run complete benefits.
What are Benefit Navigator and RTB (Real Time Benefits)/Streamline?
This is the name of the form that can be submitted from the primary insured to allow someone else to receive policy information.
What is a Standard Authorization Form (SAF)?
A specific dollar amount that must be met by the member before benefits covered under the insurance plan will be paid.
What is a Deductible?
This is where you can find alternate policies the members may be covered under.
What is the Other Membership drop down menu?
A High Deductible PPO Policy that can include either a Health Savings Account or a Health Care Account to assist in lowering Out of Pocket Costs.
What is a Consumer-Directed Health Plan (CDHP)?
There is a $50,000 fine for not doing this two step process.
What is asking for the phone number and verbally verifying it back to member?
A group of physicians, hospitals, or other health care providers who have contracted with a health care plan to deliver medical services to its members.
What is In - Network providers?
This is where you will find if the policy is AEP or not.
What is the Account Details sub-tab under the Membership tab?
When running benefits for an outpatient surgery, there are three different benefits you have to run. What are they?
What are institutional surgery, professional surgery, and anesthesia benefits?
If this type of restriction is showing, you cannot share this member's information with any one else but them. Also, they may have an alternate address to send correspondence to.
What is a CCRF?
The period of time set up to allow members to choose from available health insurance plans, usually once a year.
What is an Open Enrollment Period?
This is where you will find information on the member's Continuation of Coverage.
What is the COBRA Information sub-tab under the Membership tab?
What benefits must you run for complete Maternity Benefits?
What are Maternity Professional Inpatient, Maternity Institutional Inpatient, Anesthesia Inpatient Professional, and Maternity Outpatient Professional?
The Primary Insured's spouse not on policy calls in wanting info on a dependent child's claim. If HIPAA is verified for child, can mother receive information?
Not without an SAF or a One Time Verbal Authorization from Primary Insured.
The maximum amount a health care plan will reimburse a doctor or hospital for a given service.
What is an Allowed Amount?
This is where you can find who the coverage vendor is. (ex. Dental, Vision, RX)
What is the Coverage Vendor Tab under the Membership Effective Dates?
This Healthcare Reform (Law) took effect and changed the way healthcare is offered and covered today. Examples of changes include preventative services being covered at 100% and no exclusions of coverage for pre-existing conditions.
What is the Affordable Care Act?
These are the six Blue Distinction services.
What are: