INTENTS
INTENT USED FOR MEDICAL CLAIMS
REVIEW MEDICAL CLAIMS
NON FORMULARY MEANS..
THE PRECRIPTION DRUG IS NOT A COVERED DRUG ON THEIR PLAN
MEMBER QUALIFIES FOR ASSISTANCE WITH PREMIUM
LOW INCOME SUBSIDY (LIS)
LATE ENROLLMENT PENALTIES LAST HOW LONG
LIFETIME
PROGRAM WHERE A UHC NP GOES TO A MEMBERS HOME AND GIVES THEM A 45-60 MINUTE PERSONALIZED VISIT FOR FREE
HOUSE CALLS
INTENT USED FOR PRESCRIPTION DRUG CLAIMS
CLAIM HISTORY
THE LIMIT OF A DRUG PER MONTH
QUANTITY LIMIT
HOW MANY LEVELS OF FINANCIAL ASSISTANCE ARE THERE FOR LOW INCOME MEMBERS
4
MEMBER PAID OUT OF POCKET FOR A MEDICAL VISIT, THEY WISH TO BE REIMBURSED, WHAT WILL THEY SEND IN..
DIRECT MEMBER REIMBURSMENT FORM (DMR)
TO LOOK UP A CPT CODE AND FIND IF A SERVICE/PROCEDURE IS COVERED WHAT DO YOU USE..
KNOWLEDGE CENTRAL
INTENT USED TO LOOK UP A DRUG
FORMULARY LOOK UP
WHEN A DRUG MUST BE APPROVED BY THE PLAN PHARMACY TEAM BEFORE BEING COVERED BY THE PLAN IT NEEDS A...
PRIOR AUTHORIZATION
WHAT THE MEMBER RECEIVES DETAILING THEIR PLAN BENEFIT COVERAGE FOR EACH CLAIM
EXPLANATION OF BENEFITS (EOB)
CPAP COVERAGE IS LISTED AS
DME - DURABLE MEDICAL EQUPIMENT
YOU NEED TO FIND OUT WHICH FORMULARY TO USE FOR THE MEMBER AND MAESTRO WILL NOT PULL IT UP, WHERE DO YOU FIND IT?
THE GRIF
INTENT TO FILE AN APPEAL
COMPLAINTS, APPEALS AND GREIVANCES
WHEN THE MEMBER MUST HAVE TRIED OTHER RX DRUGS BEFORE THE PLAN WILL COVER THE DRUG BEING RX'D, THIS IS CALLED
STEP THERAPY
THE MEMBER FAILED TO HAVE CREDIBLE COVERAGE FOR SOME PERIOD OF TIME, THEY WILL INCURE A
LATE ENROLLMENT PENALTY (LEP)
MEMBER IS SUFFERING A MENTAL HEALTH CRISIS, WHAT TYPE OF CALL IS THIS
ONE BREATH
AUX YOU WILL USE FOR A MEETING WITH YOUR SUPERVISOR TO REVIEW A CALL OR METRICS
COACHING
INTENT USED TO UPDATE OTHER INSURANCE INFORMATION
COB - COORDINATION OF BENEFITS
THE MEMBER FEELS LIKE THEIR RX COPAY IS TOO HIGH AND THEY WITH TO PAY A LOWER COPAY YOU APPLY FOR A...
TIER REDUCTION
THE MEMBER STATES THEY HAD NO GAP IN COVERAGE BUT THEY HAVE RECEIVED A LETTER STATING A LAPSE, YOU WILL TAKE THEIR
VERBAL ATTESTATION
SCHEDULING AN APPT HELPS WITH YOUR___ ADH
ASSISTS
SYSTEM USED TO UPDATE YOUR ADH
IEX