Claims
The maximum/contracted amount a plan will pay for a covered health care service.
What is allowed amount?
This determines the primary insurance carrier when members are covered by more than one insurance plan.
What is coordination of Benefits?
This mandate covers items such as lancets, glucose test strips and alcohol swabs.
What is Diabetes Mandate?
Faith is a member and wants to know how much her copay will be if she sees a family practitioner and if her claim was paid. What items must be verified in order to discuss information with the member?
Member Name
Member ID
Date of Birth
Address
is the radiology vendor who provides diagnostic imaging and utilization management.
What is evicore?
From where should you start your case creation when the member is calling on a claim?
Inside the claim
In what network can the Member find participating providers in NJ?
What is Qualcare ?
A mandate that increases member protection and transparency when accessing out-of-network services.
What is Out of Network Bill Mandate?
Where can a member get a copy of the HIPAA authorization form?
Members can request a copy by calling a customer service line
Member can download the form from the website
Delegated for claims processing, credentialing, customer service, first level grievance and appeals and prior approvals. has a Medical Center number of 14HH
What is Health Care Partners?
What is the claim status when a Delegated Entity has processed the claim?
What is encounter processed?
CNY HMO Preferred grandfather RX rider has coverage for how many Tiers of Drugs?
Mrs. Rivera would like to confirm the services covered by the Women's Preventive Services mandate. Give 3
Well-woman visits
Contraceptive Benefits
Domestic Violence Screening
Andrew called to check about a copay for mental health checkup. When he provided his mailing address, he did not mention the zip code. Is this a HIPAA pass or fail?
Hipaa pass - zip code is not required for mailing address
Which vendor will you need to call if a member is in need of a Crutches supplier?
What is Integra Partners?
What document can I find the reason for the claim denial?
What is EOB (Explanation of Benefits)?
Edna wants to change her PCP to Dr. Patel. What Category / Sub-Category would you use to create a case to document your call with Edna?
Membership / Change PCP
What is required prior to having a non-emergency service?
Prior Approval
Toni called to check about her benefits. You are in the process of verifying identity from the caller. Toni gave 2/23/1992 as her Dater of Birth. Upon checking in the system, DOB is 2/16/1992. Is this a HIPAA pass or HIPAA fail?
HIPAA pass - Two-digit month and year is sufficient if the day is not available or offered.
Injectable drug benefits management company with an expertise in specialty pharmaceuticals:
What is Accredo?
When submitting a claim to be reprocessed what is the turnaround time you advise the member?
A Member has HMO plan ID MH000642. The member is at Walgreens Pharmacy being advised her medication refill for Kenalog has been rejected. What do you advise the member?
EH is not your prescription drug carrier and refer the member back to their union for additional assistance
I cover 3 cycles of IVF for Lifetime.
What is IVF Expansion Mandate?
Cynthia is calling on behalf of her daughter Danielle who is 22 years old to check on a laboratory request. Upon checking on Danielle’s account, you don’t see her listed as an Authorized Representative. Before releasing any information, what do you need to check and verify?
Ask if the member is available for verbal consent
If member is available, we can call the member’s phone and verify the following:
Member ID, Name, DOB and complete address
note: A member may grant a verbal authorization for an individual to speak on their behalf. Proper HIPAA verification must be performed by the member prior to speaking with the authorized individual. Verbal authorizations are granted for the duration of the call only.
Delegated Entity (vendor) processes Mental Health Claims
What is Beacon?