Enrollment
Member needs to change address/ correct DOB/ change last name/ change effective date. What do we need to do?
Refer to employer
Yes, they can use ER, urgent care and ambulance service for an emergency outside of NJ
Plan that must have a PCP and referrals
HMO
How telemedicine works?
Teladoc $0 and with PCP/specialist regular benefits as outpatient
How long the provider or member have to submit a claim?
1 year after the DOS
Member needs to change email address?
It's ONx member
Connect with escalation line (conference)
TRUE/ FALSE Individual plan Amerihealth advantage includes benefits OAA
FALSE
Plan that doesn't need referrals but doesn't have ONN benefits
EPO
What probing question can you ask to quote colonoscopies?
TRUE/FALSE The claim is in process, I can send a claim review route
FALSE
Member needs to reinstate the plan. It's individual ONX plan. What can you do?
Connect with GCNJ
What is the coverage are for regional preferred network?
New Jersey, Delaware and Southeastern PA
Plan that needs referral to pay less
POS
What type of vaccines AHNJ covers and how you can quote them?
Routine/ non routine. Immunizations / injections
Mention the claim types (2)
institutional and professional
Spouse calls to change address on file. It's and individual OFFx plan. What can you do?
We need to check verbal authorization or personal representative form
Where can you check provider's participation?
MVP and HRP
Plan that doesn't need referrals or PCP and has ONN benefits
PPO
What's the difference between procedure code and diagnosis code?
Procedure code is for the service rendered and diagnosis code the medical condition
What is the difference between manager exception and PARE exception?
Manager exception wrong information was shared and PARE exception ONN services for pathology, anesthesia, radiology and emergency to avoid balance bill the member
Member has questions about how the insurance can cover a newborn baby? What can you do?
Inform member newborn have 60 days coverage and offer to send place holder route
What is the name of the network that offers access to care outside of NJ? What is the vendor name?
National access, CIGNA
What services don't require referral? They have direct access
OBGYN, preventive service, emergency room
Quote benefits for physical therapy
INN/ONN, PDD, coinsurance / copay, OOPM, referral, authorization, limitations
Medical policy, procedure code and diagnosis codes