HIPAA
Health Insurance Portability and Accountability Act - federal law
HIPAA
CARE
C - Connect with the Customer on a Personal Level and Show Genuine Interest
A - Always Communicate with Confidence & Knowledge
R - Resolve The Inquiry by Taking Responsibility and Presenting Solutions
E - End with a Lasting Impression
Par and Non Par
Inn and Out of Network
EOC
Evidence of Coverage
DX code - Diagnosis code
3 Primary Pieces of information for HIPAA verification
1 - Callers First and Last Name
(cannot be substituted for any other information)
2 - Members ID - HCID
3 - Members Date of Birth
FCR
First Call Resolution
When a doctor bills you for the difference between what they charge and the amount that's allowed by your plan.
Balance Billing
C-PLO
Benefit Quote-
Covered - non covered
Provider - INN or Out
Limitation - visit limitations
Out of Pocket - ded, coins, copay, oop max
These are service codes submitted on a UB04
Rev Codes - Revenue Codes
Member ID, Health Records, Member Contact Information, and Payment/Billing Information are examples of what?
PHI - Protected Health Information
This is mandatory for a out bound call to a Live person.
Telling them you are calling on a recorded line.
These provider's cannot be assigned as a PCP
Specialists
Embedded Deductible
Everyone has their own individual ded and a family ded. Their individual ded goes toward the family ded and once the family ded is met they no longer have to pay on their individual ded.
Where you will find a claim image
WCF - Wellpoint Content Framework/FileNet
These are put in place to protect the dependents on the policy from the subscriber when they may be in danger.
CC - Confidential Communication
LEAD
L - Listen to a difficult caller
E- Empathize with the caller
A - Articulate and Paraphrase Key Points
D - Do - Take action to solve the problem
Facilities that provide palliative care (pain control and symptom relief) to terminally ill patients and supportive care to those patients and their families
Hospice
List of authorizations AIM houses
Diagnostic Imaging
Cardiovascular
Radiation Therapy
Sleep Management
Chemotherapy and Supportive Drugs
Surgical Procedures
Genetic Testing
Musculoskeletal
Rehabilitation
Where you will select Requires and Adjustment
Perform Next Action
This system houses CCs and SSCCs
CIRS - Corporate Individual Rights System
Flow of a Call
Welcome and Greeting
Caller Ask - How can I help you? (start taking notes here)
Clarify the Need
Investigate
Offer a Solution or Resolve
Wrap Up
Post Call
When Anthem gets a new member and the member's provider that they are undergoing treatment with is now OON. This allows the member up to 90 days to locate an INN provider.
Used to search for Clinical UM Guidelines for a service
OMPTA
A claim that has a SCCF number
an ITS - Blue Card claim