M&R Core
M&R means?
Medicare and Retirement
Tool used in viewing member's diagnosis and Medical Prior Authorization status
ICUE
The document that describes any changes to the Member benefits, coverage, costs, premiums and/or service area that will be effective in the new plan contract year.
Annual Notice of Change (ANOC)
A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.
HIPAA
A third-party caller should obtain __ when speaking on the member's behalf.
Verbal Authorization
Also known as Medicare Advantage
Medicare Part C
Houses all SOPs and jobaids
Knowledge Central
A set time each fall when Medicare Advantage (MA) AND Medicare prescription drug coverage Members can change their health or drug plans or switch to Original Medicare.
Annual Election Period (AEP)
Examples of Caller Types
Member
Authorized Representative
POA/ Guardian / Conservator
Trustee
Attorney
Broker
Employer Group
Foster Parent (C&S Only)
Insurance Company
Internal Caller
Media Representative
Parent / Guardian of a Minor
Provider
SHIP Counselor
Third Party- Others
Federal / State Regulator (SPAP, CMS, State Medicaid Agency
HICN Number
A Federal insurance program that caters individuals over 65years old and/or having long term disabilities
Medicare
Tool used in scheduling HouseCalls
PCSS Tool
A department within the Plan responsible for answering questions about membership, benefits, grievances, and appeals.
Customer Service
True or False: We are allowed to disclose general information about the member's account if the caller is not the member
True
The amount paid out of pocket by the policy holder before an insurance provider will pay any expenses.
Deductible
Medicare Open Enrollment Period
October 15-December 7
A tool used to locate existing HouseCalls appointments or missed HouseCalls.
Housecall/Member Status (optum.com)
A list of prescription drugs covered by the plan. The list includes both brand name and generic drugs.
Formulary
True or False: A new email address cannot be added without the member’s verbal consent.
True (Ref KM1007997)
Intent used if member is requesting a comprehensive formulary list
Member materials
A Federal agency who is responsible for the oversight of Medicare and Medicaid
CMS- Center for Medicare and Medicaid Services
Tool used in punching auxes according to the given schedule.
Genesys
Refer to Non-Contracted Provider
OON (Out of Network)
True or False: If the caller is a broker, member does not need to be present to provide permission; the broker only needs to verbally attest that they have received permission from the member.
True (Ref KM1004106)
Gaps in care
Next Best Action (NBA)