Session 19 & 20
Refers to all health care benefits related to eye care and eyewear
What is Vision Services.
This type of service focuses on disorders of the musculoskeletal system and the nervous system. Services are most often used to treat back, neck and joint pain and headaches.
What is chiropractic services
Urgent care will have a separate line in the plan's benefits, the wording will include what two styles
What is new style and old style.
The term used when there are circumstances where a participating specialist is not available in the member's service area
What is Network Inadequacy.
The two benefit lines to quote when reviewing Allergy benefits
What is allergy injections and phys allergy test/treatment.
A Physician that isn't identified as family practice, general practice, internist or pediatrician
What is a specialist.
There are times when you may need to complete an outbound activity. When this occurs, you'll need to document the outbound activity using these steps:
What is access GPS, go to Case tab, then Center Panel and then Activity.
Administers an authorization for specific high-tech radiology procedure services
What is The Enhanced Clinical Review Program (ECRP).
Two covered services under basic fertility
What is Diagnostic testing to confirm the cause of infertility and surgery to correct an underlying medical condition that could be contributing to the infertility.
Two additional levels of non-standard Maternity benefits
What is Comprehensive infertility and Advanced Reproductive Technology (ART) benefits.
The vendor of the Aetna Vision Discount Program
What is Eyemed.
This is a form of electronic communication that instantly links the provider's computer systems with Aetna's computer systems
What is Electronic Data Interchange (EDI)
The two possible locations in GPS where speech therapy will display if it is a covered benefit
What is the speech benefit line or within the Short Term Rehab (STR) benefit line.
For HMO product on ACAS these are the two procedure types you will need to know
What is surgical vs. non-surgical.
For HMO product on ACAS these are the two Places of service you will need to know
What is hospital and ambulatory surgical center.
Routine hearing screenings are a covered benefit when performed by what type of provider and for what type of visit?
What is a primary care physician (PCP) and as part of a preventive care visit.
What does it mean when the members benefit maximum is stacked
What is the in-network and out-of-network benefit maximums are accumulated separately
Members may call stating that they need this to be sent to them in writing in order to obtain a visa
What is a travel benefits letter
An administrative procedure where a medical professional submits a treatment plan to the insurance carrier before treatment begins
What is a predetermination.
When a physician administers chemotherapy, they usually submit a bill for these two components of the service
What is CPT codes representing services for administering the chemotherapy drug and J Codes representing the actual chemotherapeutic drugs
Not all plans use usual and customary rates for out-of-network charges. Plan sponsors may also choose to use
What is Medicare rates, Aetna Market Fee Schedule, Fair Health, etc. to base out-of-network payment and patient responsibility
The policy that protects members when they aren't able to choose which providers perform additional services while they are having a service preformed through a participating provider
What is the RAPS/HAIRPENS policy.
Emergency care is warranted if a prudent layperson could reasonably expect the absence of such care to result in any of the following three outcomes:
What is loss of life or limb, significant impairment to bodily function and/or permanent dysfunction of a body part
When an authorization is denied and the member does not want a re-evaluation summited they do have a second option. What is this second option and how does a CSR handle making this request
What is the provider that is performing the service can request to speak to the medical director that performed the review. CSR's would send an email to the NCAU-MPPA Callback mailbox to request a call back.
When an authorization is denied re-evaluation can be requested, following these to regulations:
What is only one re-evaluation review is allowed and the request for re-evaluation must be within 6 months of the denial.