Medicare Terms
Part A of Medicare, other wise known as :
Hospital Insurance
What does inpatient mean ?
Inpatient refers to being admitted to the hospital with a doctor's order.
There are two different types of exceptions our pharmacy department may choose to grant based on a member’s individual need.
A tier exception or a formulary exception.
Social Security does limit the amount that can be deducted from a members social security check.
TRUE
Name at least 2 procedures could fall under EviCore's authorization/approval.
Cardiac Imaging
Cardiac Rhythm Implants
High Tech Radiology
Pain Management
Sleep Study
Part B of Medicare, otherwise known as :
Medical Insurance
What does Outpatient mean ?
Outpatient refers to getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays, or any other hospital services, and the doctor hasn't written an order to admit to a hospital as an inpatient.
What is Step Therapy ?
If Drug A and Drug B both treat the medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work, we will then cover Drug B.
A member's out-of-pocket costs do not roll over from year to year, therefore the accumulators reset at the beginning of the new plan year (January 1st).
TRUE
What is an EOC?
This is the contract between Aetna and the member.
What is an Expedited Appeal?
The are filed IF waiting for the usual time could seriously harm the member’s life, health, or ability to recover fully.
What does P.E.A.S stand for ?
Paraphrasing, Empathizing, Appreciation and Summarize.
The number of Tiers the Formularies have:
Most formularies have between 3 and 5 tiers.
Power of Attorney form is valid until the members passing ( death ) :
TRUE: This form generally does not expire, however, the Power of Attorney always expires after the Member’s death.
When ember gives verbal consent for someone to speak on behalf of the member for the current call.
What is the definition of Preventative and Routine Care and name 3 examples.
Services help prevent illnesses or detect potential illnesses early.
Screenings
Vaccines
Tests
Sean is turning 65 on November 12th. He submits his enrollment application for a Medicare Advantage plan on November 24th. Sean's plan effective date is December 1st.
Since Sean is newly eligible for Medicare, his application is processed using the :
IEP : Initial Enrollment Period.
Name the 3 stages of LEP :
Attestation
Notice of LEP
LEP Reconsideration
LIS ( Extra Help ) is only offered to Dual Special Needs members.
False: the Medicare Part D Low-Income Subsidy (LIS), also known as Extra Help, is not only for dual-eligible members. Anyone who meets the program's income and resource limits can qualify.
When this occurs, the claim must be reviewed to confirm that Aetna is coordinating with the other insurance correctly. In some cases, Aetna may need to update the member's account by adding, updating, or deleting other insurance information.
Coordination of Benefits
What does CTM Stand for ?
Complaints to Medicare
What is an Organization Determination ?
Plan members have the right to request a decision regarding healthcare payments and coverage of services.
What is a Coverage Determination?
Plan members have the right to request a decision regarding prescription drug coverage.
Open Access HMO : This plan requires PCP on File and Referrals.
False : Open Access HMO plans provide members with direct access to participating providers without a PCP on file or a referral.
On the Appeal process: how long does a provider have to submit any requested Medical Records related to the abover?
24 hours