Week 6
Supplemental Dental Benefits can be offered and administered through:
Aetna
Liberty Dental Plans
Define Loss of Entitlement (LOE)
Beneficiary has lost either Part A or B of their Medicare Entitlement.
What is the name of the program Aetna has that offers member discounts and other helpful services?
Value Added Items and Services (VAIS)
The Care Management Team is made up of four groups:
what is DSNP
Special Needs Plan for members eligible for Medicare and Medicaid.
On rumba rate what letter do you use to identify Emergency ?
E
What is the document sent to our members that explain how claims were processed?
Explanation of Benefits
What do we usually call the brokers who are hired to help sell NextGen Medicare Advantage plans
Strategic Partners
What is TAT
Turnaround time abbreviation.
In California there are many ______, also known as _____
Individual Physicians Associations, also known as IPAs
What happens during the Deductible Stage of a Medicare Prescription Drug Plan?
The member pays the full negotiated cost of medications
How long can the rework process for a claim take?
Up to 30 days
If the member does not recertify prior to the loss of eligibility, the member is allowed to stay in the DSNP for up to______
6 Months
what is a precertification
Prior approval required before certain services are covered.
What is Capitation
The method of payment in which we pay providers a fixed amount (once a month) for each member service, regardless of the actual number of nature of services delivered.
Low Income Subsidy is a program for Medicare beneficiaries that helps with ____-
Reducing, or eliminating copayments, coinsurance, or deductibles for medications.
What is a non-keyed claim and how is it handled
A claim received but either not processed or keyed incorrectly, requiring submission through a Quickbase form to the claims department
Members are notified approximately ______ prior to losing their Medicaid eligibility and are encouraged to recertify to keep their Medicaid eligibility.
45-60 days
what is SNF
Skilled Nursing Facility abbreviation.
What is Claim Type used for on HRP
This field Identifies what kind of claim it is, professional (CMS 1500), Institutional (UB04) or Dental.
What internal support team can assist you with researching enrollment eligibility inquiries for Medicare members?
Medicare Internal Urgent Support Team (MIUS)
What should you tell a member who calls to check the status of a submitted reimbursement?
Reimbursements take up to 45 days to process, and checks are sent 7–14 days after processing.
______is a public assistance healthcare program for low-income Americans regardless of their age. ______, on the other hand, is an age-based federal health insurance program that guarantees coverage for individuals ages 65 and over and some younger people with disabilities.
Medicaid is a public assistance healthcare program for low-income Americans regardless of their age. Medicare, on the other hand, is an age-based federal health insurance program that guarantees coverage for individuals ages 65 and over and some younger people with disabilities.
What is HMO and what does it require
MAPD Plan that typically requires a PCP and referrals.