AEP
October 15th-December 7th
This is the OE dates when members are allowed to make changes to their plan.
October 15- October 31, 2021
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 4 stages of pharmacy coverage per Medicare.
Deductible, Initial Coverage, Coverage Gap and Catastrophic.
Donut Hole also acceptable instead of Coverage Gap.
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.
Eligibility and Enrollment Support Center
Also acceptable:
EES
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 you should have up on all claims calls
Identify Claim Status and Details
AKA $6,550
TrOOP
also acceptable:
True 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.
Handles billing/deduction questions, not to be confused with premium rates and costs
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.
You can sometimes get help/more insight by calling this team of individuals before 5:00PM about a claim that has been reprocessed or corrected.
Phone a Friend
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
Make sure you don't do this prior to October 1st of every year.
Bonus Question: 200 Points
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.
Transfer to DMS if applicable.
Bonus Answer:
ANOC/Annual Notice of Change
This NCSHP 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 an internal denial that means there is another claim in CAS that you should look at and advise on, instead of the one with this denial code. This usually happens when a corrected claim is sent in or an original claim is reprocessed but you must always provide details on only the original claim.
Bonus Question: 200 points
Where in CAS can you find the original claim number? CAS screen and CAS field
DAILY DOUBLE
OYU
Bonus Answer:
MHI screen and RFM Field
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
Also Acceptable:
Coverage Determination