Medical Benefits
What is a deductible?
Amount the member must pay out of their own pocket before Humana will pay any expenses.
What tool is used for quoting benefits?
DEBUT
Advocates quote dental benefits for services covered under which plan type?
Medicare Advantage (Part B) medical plan
What is the maximum out of pocket (MOOP)?
The max amount a member pays for their covered medical costs in a plan year.
Where can you find benefit restrictions and limitations?
Evidence of Coverage
Members with a hearing rider can choose between which hearing vendors?
Truhearing and HearUSA
What are the PARE providers?
Pathologist
Anesthesiologist
Radiologist
Emergency room doctor
Medical supplies are ______________ items used by a physician or patient.
Usually one-time-use
What does "off-label" mean?
Using an FDA-approved medication for an unapproved use.
A member asking for benefits to see an allergy specialist would be quoted which benefits?
Physician Services
When there's no Medicare coverage guidance for the service what tool/document would you access?
Medical Coverage Policies Database aka Coverage issues
What is the difference between Part B and Part D drugs?
Part B: Medications used with Durable Medical Equipment or received from a hospital, home health setting, rehab, or LTC facility.
Part D: Medications administered or dispensed at a pharmacy or doctor's office (not covered by Part B).
What is the complete VOB process?
Quote benefits
Verify provider network status
Verify if authorization/referral is needed
What additional benefits should be offered to callers when quoting surgery benefits?
Anesthesia and Diagnostic Testing
Which is a high-cost Part B covered wearable device with sensors inserted under the skin that continually test and monitor glucose levels?
Continuous Glucose Monitor