Benefits
Fred Myers visited his PCP, he has a fixed amount he pays to the PCP. What is this called?
what is a "copay"
It is ONLY considered _______ _______ if the provider continues to bill for more than the member cost share shown within the claim after the claim(s) has been processed/paid
What is 'Balance Billing'
what AEP stands for
What is Annual Election Period
this intent is used when assisting members with rewards questions
what is the 'rewards intent'
This Maestro intent is used to quote prescription benefits and copays
What is the 'review prescription benefits intent'
Hattie Brown called because she needs a wheelchair, what benefit is the member calling about?
Durable Medical Equipment (DME)
____________ __ ________ is the process for determining and processing a claim in conjunction with another insurance coverage
What is 'Coordination of Benefits (COB)'
The AEP time frame
What is October 15-December &
three rewardable activities for employer group
what are the- 'annual wellness visit, provider check-in, paperless delivery, text messaging'
(only need three answers)
The period after the member has met their True out of pocket (TrOOP) cost for the benefit year
What is 'Catastrophic coverage stage'
the set amount, a member must pay, before his plan start paying on his claims
what is the 'deductible'
Where a member can see their medical claims
What is the 'EOB or Online'
What OEP stands for
what is 'Open Enrollment Period'
This is done when a member has lost their reloadable vida card and needs to order a new one
what is 'transfer to Visa'
This intent is used when a member is requesting a Non formulary Medication to be covered
What is the 'CAG Intent' (complaints appeals and grievances)
David Beckman called, because he has a doctor appointment scheduled and needs a ride, what resource would we use to help the member
what is 'SDOH' or 'Social determinates of Health'
If a Claim is not found when searched, what 2 questions should the advocate ask the member?
1)Ask the member if this is a member reimbursement.
2)Has it been more than 30 days since the date of service?
The OEP time frame
What is 'January 1 - March 31st'
This Job aide is used to assist members with rewards questions
what is the '2023 rewards- index'
Also known as the donut hole, this coverage stage only covers 25% of prescription costs for non LIS members
What is the 'Coverage gap'
this is the max a member will pay in a year for health care services
what is the 'Out of Pocket Max' or '(OOP)'
If a member states they paid out of pocket for a medical service, the advocate should offer this to a member
What is a 'direct member reimbursement form' or 'DMR'
What CAHPS stands for
'Consumer Assesment of Health Providers & Systems'
Do members need to sign up for the rewards program each year?
yes
This is used to keep costs low, it requires members to try different less expensive and equally effective medications before being approved for specific medications called out on the formulary
What is 'step therapy'