Benefits
Is my Plan Active? If so, what's the effective date of my policy?
Yes, Effective date: 01/01/2019
What is the definition of D0120?
An evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. The findings are discussed with the patient. Report additional diagnostic procedures separately.
Where can I find the Printer Friendly Version of Doc-Find?
CS Toolbar/Folder > Aetna Websites > DocFind Printer Friendly
Where are the two places in GPS under the member view that you can use to locate the plan sponsor profile page?
To access the PSPP, go to Menu Navigation > Plan Sponsor > Plan Sponsor Profile Page.
Places To Go > Helpful Resources> Plan Sponsor Profile Page.
Where are the two places in GPS under the member view that you can use to locate the plan sponsor profile page?
To access the PSPP, go to Menu Navigation > Plan Sponsor > Plan Sponsor Profile Page.
Places To Go > Helpful Resources> Plan Sponsor Profile Page.
If Kelsee goes to the office to get a sealant performed on tooth #06, will the service be covered by Aetna?
What is the definition of D4341?
Periodontal Scaling and Root Planing, four or more teeth per quadrant. This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.
Do I handle CA DMO member calls? If not, where do I find the transfer code information to get the member over to the correct department?
No > CS Toolbar/Folder > Dental Tools and References > Job Aids > Take the Call Where is Lands
How should you offer the survey to your caller before disconnecting the call? Where can you find information pertaining to survey offering?
"To help us improve, do you have a few minutes to take a brief survey regarding the service you received today?"
ePolicies > Contact Servicing > Contact Servicing - Customer Service > Call Procedures: Call Closing - Survey Offering - Member
What is a qualifying life event? When a member experiences a qualifying life event, what can the member do with their plan?
A qualifying event is a life event (e.g., marriage, divorce, birth/adoption, termination of employment, etc.) that allows an individual or family to enroll in/change an exchange plan outside of the open enrollment period.
How is coordination of benefits covered under my plan?
Standard - 100% ALLOWABLE EXPENSES (NON-PROFIT) - CALENDAR YEAR. ALL GROUP PLANS. INCLUDES NO-FAULT BENEFITS
What is the required documentation we need to consider the procedure code D4265 for payment?
Narrative
Material Used
Agents
Drugs used for this treatment
Where can I find important updates about Dental? I need to review this at least once per day.
CS Toolbar/Folder > Start My Day
What are the 3 steps you should take to fully resolve a member's issue?
Step 1
Step 2
Step 3
Under the member's plan in GPS, where can you locate the member details tab? What information falls under the Member details tab? (please provide all information listed there)
The member’s policy information is viewable in GPS on the on the Membership screen. To access, click on the Policy Name blue hyperlink to open the Membership information tab. You can view the Membership, Membership Info, and Health Policy Information.
The pop-up box displays information such as:
NO, PREDETERMINATION OF BENEFITS IS RECOMMENDED IF EXPENSES EXCEED $350.
What documentation is required to be submitted over to us for us to consider the procedure code D2950 for payment?
Pre-operative and post-operative photographs showing the buildup in place
OR pre-operative and post-operative radiographs showing the buildup in place
Note: a pre-op and post op is required (this can be a combination of x-ray or photo)
Where can I find information on CPI?
CS Toolbar/Folder > Service with Heart Initiatives (CPI)
Dental CSRs only handle calls from members and providers regarding claims, eligibility or benefits for the dental product/plans. What type of products would you need to transfer the caller over to a different customer service center for?
What are the reasons a member's plan may terminate? This information can be located in the Eligibility Sharepoint.
There are times when a member is no longer active under a plan. Examples of why a person's coverage may terminate are:
Kelsee needs to render a D4910. Please provide the full breakdown of benefits. She is going to an In-Network provider.
D4910 - Major @ 50%
Service does apply to the deductible and maximum.
Frequency - Perio maintenance 2x per cal year following active periodontal therapy.
Current dated pre-operative periodontal charting ●
Current dated pre-operative radiographs ■
Chart Notes that include administration of local anesthetic and details regarding the treatment performed
Length of appointment
NOTE: Chart notes must be in writing from the provider and cannot be accepted over the phone.
We require a copy of the actual chart notes for the DOS.
Where can I find the Claim Documentation Guidelines DR 08-01?
CS Toolbar/Folder > e.Policies - Most Common DRs
CS Toolbar/Folder > e.Policies - DCs-DRs > DRs by Number
What is a post call task?
Post call tasks are service requests that a CSR couldn't complete during the course of the initial contact. This follow-up work is added to the Tasklist to be resolved at a later time. These tasks are completed between calls or during scheduled post call work (PCW) time.
What DR should you look at when a Freedom of choice member wants to switch their plan type? This DR is also used when member's want to switch their PCD.
ePolicies > Dental > DR Policies > DR 03-15 - Provider/Plan Switches