HMO
What does HMO stand for?
Health Maintenance Organization.
Name 6 pieces of information you can ask for inorder to authenticate an account
MBR ID
Date of Birth
ZipCode
Group Name
Group Number
Plan Type
PPO members can only get services from In network Dentist is this true?
This is not true. They can go Out of network, however benefits are paid at a lower rate. While INN services are provided at a discounted rate.
We only assist Central States Team care members with dentists but how do you identify them?
Their Mbr Id begins with TEA/806
What does MSB stand for?
Mandatory Supplement Benefits
Is the HMO plan an IN Network or Out of Network plan?
Its an in network plan.
What must you select if the mbr is on the line calling for themselves?
Interacting With and About
PPO members must have a PCD
Home Office members/ Humana Inc Members are?
People who work for Humana and have Humana's Insurance
All medical plans have a Medicare MSB attached to it.
No. Some medical policies do not have an MSB attached.
What kind of Dentists qualify as PCDs?
General Dentists and Pediatric Dentists
If the call comes in Authenticated in Green you should?
Confirm the name of the person you are speaking to and if is the same name on the account you proceed with the call
The Abbreviation PPO means
Preferred Provider Organization
A pre-determination/ Preauthorization is usually recommended when the member is estimated to do services above how much money?
$300
How do you identify an MSB in CRM
An MSB has (POS) and Group name showing Medicare Dental
IF an HMO Mbr needs to see a specialist what must their PCD DO
Their PCD has to refer them to a specialist
IF a member´s daughter is calling for them but their daughter is not on the policy, how do you create that interaction?
You must click interacting about beside the member´s name in CRM then enter the daughters name in the interaction log
What is a waiting Period
A period of time the mbr has to wait before they can access certain benefits
The Acronym M.O.M means
Member Out the Middle
A member with an MSB pays a premium.
No, a member with an OSB pays a premium not an MSB.
What is the member's annual deductible and Coinsurance for preventive services on an HMO?
HMO members do not pay deductibles or coinsurance. Instead, they pay a co-payment.
If John is calling for his wife´s account and he is able to authenticate her information what else must verify before you proceed
You can ask for verbal consent, Verify POA status or verify if they have PHI Consent
For all PPO plans Humana pays the same INN and OON of Network
No Humana pay less OON as Humana pays based on the allowed amount
Mbrs with group name ERS (Employee Retirement System) should be transferred to?
Delta Dental
The member has two plans, an MSB dental policy and a policy beginning with five zeros. The member stated they are calling in for their dental that they are paying for. What do you do?
Warm transfer the member over to the CompBenefits department.