AEP
October 15th-December 7th
SEIB retirees do NOT get this option when it comes to their medications
CWP
This process provides detailed information on plan benefits, including limitations and exclusions that includes copays, coinsurances, deductible and MOOP.
Verification of Benefits or VOB
This is the next step for a member or provider when a claim is denied.
Appeal
you add this many days to the date to a COB pharmacy override was completed for a member with incorrect coordination of benefits.
+30 days
This document is sent out prior to the AEP/OEP to outline changes to the plan in the upcoming year versus current plan year.
ANOC/Annual Notice of Change
CCS will complete this template when members tell them the provider does not accept Humana.
Provider Outreach/Provider Outreach Form
Member must meet this to be covered at 100% for the remainder of the plan year.
Maximum out of Pocket or MOOP
A claim
These are referred to as the 3 stages of pharmacy coverage per Medicare.
Deductible, Initial Coverage, and Catastrophic.
.
January 1st-March 31st of every year or also
Within the first three months a newly eligible Medicare member obtains Original Medicare parts A and B
The Open Enrollment Period.
You refer the member here to make changes to their plan and inquire about premium rates.
This is only an estimation of benefits, all payments are subject to policy guidelines, medical necessity and member eligibility at the time services are performed.
Benefit Verification disclaimer/ VOB disclaimer
This is the mentor document that helps walk you through how to provide a claim status to member.
Identify Claim Status and Details
AKA $2000
Pharmacy MOOP
also acceptable is MOOP, Max out of pocket
The request with the most recent application date is the plan that takes effect when this happens.
Multiple applications/Multiple applications received.
CCS will refer to this for the most frequently asked questions regarding this group
SEIB FAQ
This is the information CCS is required to give/log for all VOB calls.
DAILY DOUBLE
Copay/Coinsurance, Plan year, deductible info, MOOP info, PAR status, Auth required/on file and benefit disclaimer.
Once you research a claim, and find out it's been processed incorrectly, you would route your case to this team for review.
CRU
All ingredients in this type of medication must be covered for the medication to be covered under the plan.
Bonus Question: 100 points
Where can the ingredients for this type of medication be found?
Compound Drug
also acceptable:
Compound Medication.
Bonus Answer: RxNova or RxNova Call Connect
You should also never review any upcoming plan benefits that aren't listed within this document or other future enrollment plan docs sent to member.
ANOC/Annual Notice of Change
This SEIB plan type means the INN benefits are the same as the OON benefits as long as the provider agrees to send the bill to Humana.
Transitional PPO plan
Also acceptable:
Passive PPO plan
Step 4 in the call procedure verifies this info, which sometimes can change how much the member or Humana pays on a claim. It may also determine if the member is able to see a certain provider.
PAR status/ Provider in network
This is the document you would use for more info and next steps for claim denial codes
MTV and CAS EX Codes Guide
This is a Medicare required process the CCS must offer to help initiate when the member indicates or implies that the cost of a medication is too high or not affordable.
Tier Exception