1
What is a premium?
The amount you pay for insurance coverage each month
Where would you find a provider in GPS?
Find Care
It is a charge applied each month if a member went 63 days or more without creditable coverage.
Referrals are needed to see a specialist, while precertifications are required for certain medical procedures or tests.
What is a post-service appeal?
A process to challenge a decision made about coverage after treatment has been provided.
Where would you find a members benefits in GPS?
Benefits tab
What is a late enrollment penalty (LEP), and how can it affect the plan s premium?
It is a charge applied each month if a member went 63 days or more without creditable coverage.
What is SFE
Smart front end
Can a claim be denied due to a COB issue
yes
System we use to listen to our calls
Verint
When member moves OOA and needs to enroll into a new plan, who do we transfer to?
Telesales
Name of our phone system in GPS
Cisco Jabber
When a member submits for a claim reimbursement, what system can we check to confirm delivery?
Electronic Correspondence Handling System (ECHS)
How will you do an update/change address?
Follow the guided workflow in GPS.
Besides GPS, what system can we use to get more details about a claim?
A. MARx
B. EPDB
C. HealthRules Payor (HRP)
D. STARs Central Portal (SCP)
HealthRules Payor (HRP)
What is a pre-service appeal?
A process to challenge a decision made about coverage before a medical service is given.
When might you need to use EPDB?
When you may need to verify a doctor s network status outside of GPS.
When would we offer a pre-service expedited appeal?
When a member has a procedure scheduled next week and we denied the authorization request.
When would you do a temporary address change?
When a member is staying at a different address for a short time, like during a vacation or while visiting family.
Which are true about Electronic Funds Transfer (EFT)?
A. Only certain members qualify.
B. Premiums are withdrawn between the 10th and 15th of the month.
C. Adding and changing account information can be done by the CSR.
D. Member will need to send in a blank check.
B. Premiums are withdrawn between the 10th and 15th of the month.
C. Adding and changing account information can be done by the CSR.
What do we need to confirm if a provider is participating in the member s network when using EPDB?
A. Network ID
B.Gender
C.Phone Number
D. Product (MEHMO or MEPPO)
A. Network ID
D. Product (MEHMO or MEPPO)
Why might a claim be denied due to coordination of benefits (COB)?
The member has more than one insurance plan, and the claim needs to be processed by the primary insurance first.
What system houses Medicare appeals, grievances, and case tracking messages (CTMs)?
MedHok
What does enrollment cancellation mean?
It is when a member decides to stop their enrollment in a plan prior to the plan s effective date.
What happens if a member moves out of their service area?
A. They can keep their current plan without any changes.
B. They will qualify for a Special Election Period (SEP) to choose a new plan.
C. They must wait until the next enrollment period to make changes
D. They will automatically be assigned a new plan.
They will qualify for a Special Election Period (SEP) to choose a new plan.
What are some important things to know about Social Security premium withholding (SSPWH)?
It can take up to three months for premiums to be withdrawn from a member's check.
The request can be submitted by Member Services.