When a the responsiblity for Claims and Authorizations are given to a PMG
What is Delegation
100
The reason why the member called
What is Catiegory
100
MA-PD
What is Medicare advantage with Perscription Drug coverage
100
Occure when MARX reflects an LIS level The memeber agrees with an either ILead or RX claim do not. Resolution Requires requesting an Ilead and Rxclaim update To Match MARX
What is LIS discrepancies
100
Who can Request a PCP change ?
Who is a member :a member and a authorixed Representatives
200
Per Member Per Month
What is Capitation
200
The Task at hand
What is an Intent
200
PDP
What is Perscription Drug Coverage
200
Occure when Memebr disagress with the LIS level in Marx . Resolution Requires Reseaching a members LIS lever Using Beas Available evidence
What is LIS Disputes
200
California applies this rule for all the PCP changes
What is the 1st and the 15th rule
300
Medical group assumes ALL financial risk for both the Hospital and medical Group
What is Global Capitation
300
Drilling down further into the issue
What is the request type
300
The SSA or state Medicaid office determines if individual qualifies for Extra help or LIS
What is True
300
The tesm used to describe the medicaid award status when the membes income is greater than the state defined limits
What is Medicaid Spend Down
300
Name the 3 types of PCP changes
What is : Standard /routine
Retro request
UCLA
400
The medical group assumes all financial risk for the medical group's services and secure horizons Assumes all financial risk for the hospital services.
What is Shared Capitation
400
They way you close a call
What is Wrap-up
400
Hospital Coverage
What is part A
400
Provide the order of the elections for PDP
What is IEP, SEP, AEP
400
48 hours is the standard turn around time for the member to receive a call from someone in the physicians office regarding a final decision.
What is Urgent Retro Change
500
Medical group assumes all financial risk for the medical claims and the hospital assumes all financial risk for hospital services;but securehorizons ( plan ) assumes SOME of the risks for the hospital services.
What is Solit/Partial
500
This can be accessed on any screen in miim to get the the account summery
What is review account summery
500
Hospital and Medical Coverage
What is Part A and B
500
True Out of Pocket
What is TROOP
500
Provider or health care facilities which are part of a health plans network of providers with which it has negotiated a discount .