If I am a HIP HMO member who do I see for lab services?
Quest Diagnostics
100
Mrs. Brown has a Comprehealth EPO plan and she would like to know who covers the dental services for her plan. How can you assist the member?
DentaQuest is EH Dental Vendor. Provide the number of DentaQuest to Mrs. Brown or transfer her.
100
What are the two City groups under the Vytra Premium network that EmblemHealth works with?
400H031 and 40049
100
What are the networks associated with HIP Commercial Plans?
NY Metro Network
Prime Network
100
Aubrey has just received her HIP Select PPO card, but she does not have a dentist listed. Who should the member speak with about choosing a primary care dentist?
DentaQuest
200
I am a HIP Prime Member my ID does not indicate a PCP, am I required to elect a PCP? Yes or No
YES
200
Michael is new to the Select EPO plan, he needs to know if he needs a referral to see a specialist. What would you advise Michael?
No, referrals are not required on the Select EPO plan
200
What network would a member need to be apart of in order to access providers in New Jersey and Connecticut?
Prime Network
200
Gary switched his Access I plan for an Access II plan. He was told by his doctor that cost-sharing would apply for services. Is this true? Yes or No
YES
200
John, a HIP Select PPO member, needs to know who manages the chiropractic services for his plan. How would you educate this member?
Advise member that Palladian takes care of Chiropractic services.
300
I am new to HIP member and was advised that if I select ACPNY or CMO my copay is $0 or at a reduced cost if the services are rendered by a ACPNY or CMO provider. Is this correct? Yes or No
YES
300
David is a HIP Select EPO member who resides in Connecticut. Her PCP's office is also in Connecticut. Would her PCP be considered in-network or out-of-network for her plan?
Yes, the PCP would be in network.
300
Ms. Robinson has a HIP Access I plan, her doctor informed her that she needs to get an MRI of her left arm. Who would authorize approval for this type of medical service?
Evicore
300
Joey has an HIP Access I plan and he wants to see a specialist today. There is no referral on file. Can he still go to a specialist today? Yes or No
YES
300
Dr. Paah an OON podiatrist, would like to request a review of a claim that was denied for no referral for a HIP Prime PPO member. Did the member require a referral to see a specialist?
HIP Prime PPO members do not need referrals
400
I am a HIP Preferred member, I was advised by my PCP to see an ophthalmologist. I do not need a referral for this? True or False
FALSE
400
Abigail has a HIP Prime PPO plan and is traveling to New Hampshire next week. Can she use her plan outside of NY? Yes or No?
Yes, HIP Prime PPO plan have In and Out-Of-Network benefits
400
Charlie has a HIP Access II plan, and would like to know the benefits of this plan over the HIP Access I plan. How will you educate Charlie?
• HIP Access II has in and out-of-network benefits
• HIP Access II has cost-sharing whereas HIP Access I only applies copays
• Both use the Prime Network
• PCP required on both plans
400
Martin has a HIP Prime POS plan and he is scheduled to see a cardiologist next week. If the provider is in-network does he require a referral?
Yes, HIP Prime POS plans require a referral for in-network services.
400
Johnny is on the EmblemHealth.com website trying to locate a doctor for his HIP Prime plan. What network/s can he select a provider from?
Prime Network
500
Dr. Smith, an OON provider would like to know why EH denied a claim for a HIP Commercial EPO member. What information do you provide to Dr. Smith?
EPO plans are only covered for In-Network services only; claim paid correctly
500
Darhyl has a HIP PPO plan, she would like to know if she is covered for medical, hospital, and pharmacy. How would you answer the member's query?
Yes, you are covered for medical, hospital, and pharmacy services
500
Edwin is enrolled in the HIP Prime POS plan and he has been scheduled for a OON surgery next week. Does the doctor need to obtain a pre-authorization for certain services when performed out-of-network?
Yes, Preauthorization for some out-of-network services may be required
500
Janine is a Prime network large group member. She will receive a new ID card in 2017 with which logos on it.
EmblemHealth
QualCare
Connecticare
500
Rachel has a HIP Prime EPO plan and she is interested in purchasing a new pair of glasses. Who would you advise the member to see for the services?