Week 2 Review

Medical Benefits

100

This requirement for select DME items must be completed within 6 months prior to the DME item being ordered. 

Face to Face Requirement or Face to Face Visit

200

This preventative visit is covered once per calendar year and does not require there to be 12 months between visits.

What is Annual Wellness Visit?

300

What are the 3 criteria that must be met for a member to be eligible for Home Health Care?

Ordered by a physician within 90 days prior to start date or within 30 days after the start date.

Must be homebound.
Skilled care needed 

Prescription Benefits

100

In this level of coverage, the member is responsible for 25% of their drug costs.

Coverage Gap

200

This list tells a member what drugs are covered by the plan and what Tier level they are.

Formulary

300

The member pays the full cost for their drugs until they reach this

Deductible

Misc

100

Some plans require this from a member's PCP to see a specialist.

Referral

200

You should always offer to do this when speaking with a member who needs assistance locating either a specialist provider or PCP.

Offer to call the provider

300

A Primary Medical Group (PMG) is primarily delegated to act on UHC's behalf for these two specific functions. 

Claims processing
Prior Authorizations