Mild
Are preventive services covered by calendar year or rolling calendar year?
Calendar Year
What is located in the MCN Policy Manager tool?
Pay Policies
Where can you locate a members Copays and visit limits?
The Summary of Benefits
How often can members make changes to their Voluntary Benefits?
ANY TIME on their Voluntary Benefits Page
What Are 5 helpful tools that can be found in KIP
–Pulling up Schedule of Benefits on EVERY call
–HealthHelp Procedure Code List
–Tip sheets (COB, HSA, FSA, UPMC Pinnacle, UPMC Somerset, etc.)
–U135 Documentation Template
–TAHS requirements/overview
–Member marketing materials (emails, flyers, etc.)
–Accessing department websites
–Dental Frequency, Limitations and Denial list
–NR codes, Bencat codes
–Preventative Service Grid
What is the limit on Mastotomy Bras?
There is no limit on mastectomy bras
Where do you check the status of a prior authorization?
Health Planet--UM cases
What is UEG's latest acquisition?
UPMC Western Maryland
What is the category code used to communicate with the consumer advantage team for HSA accounts?
What is the UEG pharmacy processing information?
003858
PMDC
A4
Do UPMC Pinnacle & UPMC Susquehanna members have level 1 access to Hershey medical center?
Yes. They do have access for services that cannot be performed at UPMC Pinnacle or UPMC Susquehanna.
Prior authorization is required for all services.
What is the category code for bariatric call backs?
When can a Member fill a script for a breast pump?
Script can only be filled once baby is born
Where can members view a list of preventive services?
MHOL account under the ‘Your Insurance --> Plans and Coverage’ section:
How do you access the PHCS or MMO website?
What are the 3 ways that Complaints and Grievances can be submitted
UPMC Health Plan Complaints and Grievances
P.O. BOX 2939 Pittsburgh, PA 15230
Fax# 412-454-7920
Online via their My Health Online Account
What information is needed to substantiate a Consumer Advantage claim?
Date of service
Description of service
Who incurred the expense
Provider/Facility information
Amount of the transaction
What are two forms members can locate via their MHOL account
Flu shot reimbursement
OON dental form
Pharmacy reimbursement form
HRA claim form
Prenatal education reimbursement form
Dentemax form
What are three benefits listed on the SPD?
•Coordination of Benefits
•COBRA
•Vision Services for a Medical Condition
•Women’s Preventive Coverage without Cost-sharing
•Contraceptive Coverage & Contraceptive Coverage for UPMC Mercy
•Medical expenses not covered
•Covered Services Under All Medical Options
•Schedule of Benefits
•Benefit Bands
•Prescription Drug Program
•Covered Dental Services
What services are handled by a select team of representatives?
Transgender
Infertility
Bariatric
Pinnacle Orthodontics
when a member uses an eligible out of pocket expense to take the place of a denied expense. In this process, the member will submit a statement for an eligible expense. They will need to write offset on the statement that is being sent in. Once received, the ineligible transaction will be approved either partially or in full depending on the amount of the eligible expense being submitted
What does the Platinum Care Program offer to members?
oThe Platinum Care rider gives UPMC employees access to the Hip and Knee Center of Excellence locations in Western PA: UPMC Passavant, UPMC Shadyside, UPMC St. Margaret, UPMC East, UPMC Magee.
What is the processing information for medical billing?
BIN#004766
PCN:COM 23281
If a member needs a vacation Override that is greater than a 90 day supply, what will we need to complete this request?
•If the requested amount is greater than a 90 day supply, we will need a dictated letter from the member’s employer or in the case of a child or spouse the card holder’s employer confirming that their employee will have continued coverage for the duration of their trip - Please fax the letter to the Pharmacy Resource Desk at 412-454-830.