Medical
Humana Gold Plus H5619-083 "My patient has experienced lower back pain for over 12 wks. due to Scoliosis, How many acupuncture visits is this member allowed and what is the cost?" ** BONUS 500pts: Are any additional sessions allowed?
Up to 12 visits in 90 days for Chronic low back pain. PA may be required- $45 copay if done in specialists office. ** BONUS: an additional 8 will be covered for patients demonstrating an improvement, no more than 20 annually
Humana Gold Plus H5619-132 What is the member responsibility for a Glaucoma Screening and any requirements?
$0 copay in specialist office available to people at high risk of glaucoma once per year
HumanaChoice H5216-237 (PPO) I have a member needing a routine dental exam, what is included in their plan? The member would be responsible for any routine dental care so this plan only offered Medicare covered dental services.
The member would be responsible for any routine dental care so this plan only offered Medicare covered dental services.
HumanaChoice H5216-075 (PPO) What is the additional hearing benefit embedded in this plan? What is the benefit?
HER941; includes one routine hearing exam per year at $0, plan approved hearing aid 1ear per year- benefit is limited to the truhearing advanced and premium hearing aids. Includes 1 fitting and 2 adjustments within the 1st yr. 45 day trial period, 3 yr extended warranty and 48 batteries per aid
Humana Gold Plus H5619-132 What coverage does the patient have for Diabetic self management training in an outpatient hospital?
Diabetes self management training is covered under certain conditions and may require a pre auth, it costs $0 for a member who meets those conditions
HumanaChoice H5216-238 (PPO) "My patient has been emotionally drained her last few visits and I would like to perform a depression screening, is this a covered service?" **BONUS 100pts: are there any OON benefits?
yes, we cover 1 screening per year at no cost to the member if in network. It must be done in a primary care setting that can provide follow up treatment. **BONUS: If the provider is OON- there is a 45% coinsurance
HumanaChoice H5216-238 (PPO) What are member benefits post cataract surgery?
one pair of eyeglasses or contact lenses after surgery at $0 to the member in any place of treatment
HumanaChoice H5216-238 (PPO) What is the supplemental dental plan embedding in this plan and how are dental cleanings covered?
DEN723; $0 deductible, Annual Max of $1000 2 cleanings per calendar year are covered in and out of network for $0
DME- Use PRO_CCR DME Rental and Purchase Guidance_REF
How is code E2313 covered?
Covered as a Capped rental
HumanaChoice H5216-238 (PPO) What are the covered brands of blood glucose monitors and test strips? With member cost?
Accu- check or Trividia products sometimes packaged under the pharmacy name; member pays $0 at a preferred diabetic supplier, 20% at a diabetic supplier and 10% at a network retail pharmacy.
Humana Gold Plus H5619-132 "I would like to perform a diagnostic hearing evaluation on my patient, is this a covered benefit?" **BONUS: if the service is determined to be routine, would the member be covered?
Medicare Covered Hearing Services- $35 copay at a specialist office. **Bonus answer: Yes, the member has MSB Hearing Benefit which allows 1 Routine hearing exam per year for $0
Humana Gold Plus H5619-083 what is the supplemental vision plan embedded in this plan? And what does the benefit include?
VIS734 includes 1 routine eye exam per calendar year which includes refraction and dilation. Member's choice of $100 towards the purchase and fitting of eyeglasses and pair of lenses at a network optical provider. This benefit does not roll over
Humana Gold Plus H5619-132 What is the routine Dental plan embedded? How many filing and extractions does the plan allow and at what cost to the member?
Den706; $0 deductible, annual max of $2000. Filings are allowed at 2 procedure codes per calendar year $0 for INN and not covered for OON. Extractions are covered unlimited when INN for erupted tooth or exposed root as well as surgical removal of erupted tooth.
HumanaChoice H5216-237 (PPO) What is the supplemental hearing benefit in this plan? How much does the member pay for advanced or premium aids?
HER941; $699 Per advanced aid, $999 per premium aid
Humana Gold Plus H5619-083 What is the diabetes screening benefit and what risk factors must be met to qualify?
$0 INN- risk factors include high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity or history of high blood sugar
HumanaChoice H5216-237 (PPO) What services are covered in my patient's long term care hospital stay and what is the cost to the member at an INN hospital? **BONUS 200pts: What if a transplant is needed during this stay?
Semi- private rooms, meals, regular nursing services, costs of special care units, lab tests, xrays, necessary surgical supplies, operating and recovery room costs, physical, occupational, and speech language therapy- costs $390 per days 1-5 and $0 days 6-90 for INN **BONUS: contact the transplant dept
HumanaChoice H5216-075 The member is requiring a prosthetic eye after Cataract removal. What benefit may cover this service and what is the member cost share?
Prosthetic devices and related supplies
INN & ONN- 20% coinsurance
PA may apply
HumanaChoice H5216-075 (PPO) True or False
Dental care required to treat illness or injury may be covered as inpatient or outpatient care
True- Review Section 3.1 of EOC
DME- Use PRO_CCR DME Rental and Purchase Guidance_REF
How is code K0738 covered?
Continuous Rental
HumanaChoice H5216-237 (PPO)
A diabetic eye exam is $0 for the member at which place of treatment?
All places of treatment
HumanaChoice H5216-075 (PPO) My patient will be leaving our hospital and is requiring physical therapy- what is his benefit to receive this service at our rehab facility?
INN- $25 copay ONN- 50% coinsurance; PA required
Humana Gold Plus H5619-132 The member needs to find an Eyemed provider in their plan's network, What directions can the provider use online to locate an Optometrist?
Humana.com> Find a Doctor> from the Search type drop down select VISION>Vison coverage through Medicare Advantage plans
HumanaChoice H5216-237 (PPO) True or False: Prosthetic devices related to dental are covered at 40% coinsurance for prosthetic providers out of network
False- Devices (other than dental) that replaces all of a body part or function.
HumanaChoice H5216-075 (PPO) "I have a member who receives home infusion therapy, can you tell me if this benefit also covers nursing services and if so what is the cost?"
yes, home infusion therapy includes nursing services covered at the professional services benefit of $15 copayment if INN and 50% coinsurance if OON
HumanaChoice H5216-075 (PPO)
Can a member with Diabetes use the Medical Nutrition therapy benefit and if so, what does it include?
Yes, this benefit is for people with diabetes, renal disease, or after kidney transplant when ordered by a doctor. We cover 3 hrs. of 1x1 counseling services during your 1st year and 2 hrs each year after